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DALZELL-SCHNEITER BLK 2 LT 6
t)alzell- chnel*ter Block 2 Lot 6 #015-291-18 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 Development Services Department Building Safety Division • • r On -Site Water and Wastewater Program, 4700 S. Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 Page of www.ci.anchorage.sk.us (907)343.7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number. \&V D 1.3 k> PID Number. 0j6_gqj_jtS Nam''Wastewater � 5�4i1+!/ R System: ❑ New Upgrade Y P9 Ad&*s` ►P, 0, 0 3) ,2 2 ABSORPTION FIELD Prime_ Nuniwr W 9abooma: Ll #-,PTtwM O Sinemo Sinew Trer O Bad O Maw O ONw: LEGAL DESCRIPTION SW Ramo 1, 2. Taal own, horn oriprW grade: a GPOXT' 1 t elo La: slbdiviaac Doper lopipe bonen ham aipaW pada: Gruel depth bwr eats pipe: /oALELt.- C.Wt`t M 1 _,f— Ft. Ft. Tovmslep'. Ranger: $Mort FA addd above crgrW pad: Gravel Ledl: ng Fr. zi Ft. Well: ❑ New ❑ Upgrade Grew malt Num dates: I l Diatanebetwea Krell: I -- F, FL Clasv&atron(Pmate. A B. cX G Total Depot cased to: Total abt rpim wec �b0 Pfe �r_ fl. Fl F?4 V Z Onear 0*0 ore Staoowar Lava adtaear D6<+rtit Data Instrlad: � n 3 i Y.eld. P'n*Se'al: Caere H9r ADo c`o r4 TANK GPM FL FL SEPARATION DISTANCES ❑ Septic 14 Holding ❑ S.T.E.P. ❑ Other. To Septic Absorption Lift Holding Pubbcmrival NarJaaua. capaaty. From Tank Field Station Tank Sewerline 1 �pGa. 'b2)wan ib 5 ✓ ✓ Maar W: STaEL Namber of canpanmerits: .2.. Sudadwwar t4 lo N n LIFT STATION Suer. MarrJrdvr. Lot LineIOU Ivy �z Gal 'Pump ai lavel at I"," oto levet a' H sh water arm at. Fera cn I 5 H F N. Pomp►Wke$Model E:scarel ;eeaona Par'rrnad bf. Certain Drien r,l Remarks ENCH MARK 1 . n Ya.C. DI a1 R/F•T.�T / /a' DetmFao Loreacn W n OT -7-c) Assumed E."auan. vr'.P A..44e— IUO,D0 Engipeefs Stamp fi • Y. %3/10 Inspections performed by: 1, S Dates: 11' T, ,2nd 7 3/o L Development Services Department Approval !J. Reviewed and approved by: Date: 13 49th o zs so � 75 tan Tzs Iso : mea AND SCALD j' = 50 FT. / rJ cc-2225 ••.�ti- _ Donm saw ASUWED W. 100.00 /T TOM& SPURKLAND P.E. LOT 6 BLOCK 2 DALZELL—SCHNEITER SID SEPTIC SYSTEM ASBUILTS 203 W 157H. AVENUE GARY SCHWARZ DATE.• JULY 27, 2002 ANCIL AK. 99501 /anal 97o_rofa 5613 DALZ£LL CIRCLE SHEET • 2/3 GRID: 2537 PERMIT I SV020236 PID 1015-291-18 D-S02062.DVG 1 • t • 'K 1 • t s- sx OP / —O 1 F STAKWO S[P11C SYSIM 1230 GAL TANK 1 IRE O so IT ONG 1 )0 E7 0 PP 6 FT SIM ROCK / 17 A7V[R 1 Ells TING TRENCH • SA1N0 TIES O I Ag 55.4 FT RVEACM SDW TANK 16.5 IVE AL VE 1250 ''AAgCCC 86 A BE H HAR1 �p ED 51 AF Lis g I gC 76 AF 93 I Bf 108 / 49th o zs so � 75 tan Tzs Iso : mea AND SCALD j' = 50 FT. / rJ cc-2225 ••.�ti- _ Donm saw ASUWED W. 100.00 /T TOM& SPURKLAND P.E. LOT 6 BLOCK 2 DALZELL—SCHNEITER SID SEPTIC SYSTEM ASBUILTS 203 W 157H. AVENUE GARY SCHWARZ DATE.• JULY 27, 2002 ANCIL AK. 99501 /anal 97o_rofa 5613 DALZ£LL CIRCLE SHEET • 2/3 GRID: 2537 PERMIT I SV020236 PID 1015-291-18 D-S02062.DVG Standard Trench, 2' Vide 50' Long 10' Deep 6.0' Sewer rock 4' Cover NV SCALE MEMO Ks ' 6 ft of Sept/c Rock Effective TO UST, [WACH c/147W VALM: O O N O o 1250 gal Septic tank Z a a V Qu s a Mon/tor NO SCALE u 805 49th SPURKLAND 1250 gal. septic tank a 3 L2 TUBBEN SPURKLAND P.E. I I LOT 6 BLOCK 2 DALZELL-SCHNEITER I I SEPTIC SYSTEM SCHEMATIC 203 W15th Ave GARY SWARZ DATE, JULY 27, 2002 Anchorage Ak 99501 $613 PAL21 l CME SHEETi 3/3 GRID- 2537 P79-3916 PERMIT I SW0200236 PARCEL ID f 015-291-18 D-S02063.DWG �C : oa�#A-7/2302 MUNICIPALITY OF ANCHORAGE Z�q.� µ7/Z3l/0Z Development Services Department f' On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Jul 22, 2002 Expiration Date: Jul 22, 2003 Permit Number: SW020236 Parcel ID: 015-291-18 Legal Description: DALZELL-SCHNEITER BLK 2 LT 6 Design Engineer: 0007 Tobben Spurkland, PE Site Address: 005613 DALZELL CIR Owner Name: Gary Schwarz Lot Size: 52823 SQ. FT. Owner Address: PO Box 231222 Total Bedrooms: 4 Permit Bedrooms: 4 ANCHORAGE. AK 99523-1222 This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: ?/'7 DZ Date: Date: 2 2 IQ Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. IM P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 i ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. Olti— a g l — 16 Permit Number SWO70236 Property owners) 1a C�1 (N w� AQ Z Day phone Mailing address (1) ti b l3 D AL 7 E Lt CA t e L C Mailing address (2) Zip Code Legal description (Lot, Block & Sub'd.) 2 �At-ZEL L - Sc F11�i t i E YL Legal description (Section, Township & Range) 7 Lot Size .707$ a,� Acres/Sq.Ft. Number of Bedrooms THIS APPLICATION IS FOR: ❑ Sewer Only � Well Only ❑ Sewer and Well ❑ Water Storage Sewer Upgrade ❑ THIS PROPERTY CONTAINS: HotTub H ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorize(; agent) Permit Fees: L4W Date of Payment: � —/g _0 Z Z7- 1 Receipt Number: b . 5 1 /�L • (Rev. 12100) / l �sH l 2'-�`f Z/ Date of Payment: Receipt Number: 'IPM 1U'c��r-E T 4 D ]F'R 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907)279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 6 BLOCK 2 DALZELL-SCHNEITER S/D GARY SCHWARZ Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street Anchorage, Alaska 99519-6650 July 17, 2002 We arc submitting an application for the upgrade of the septic system for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the septic system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: No Ground Water or Impervious Layer to 16 ft. Use Standard Trench Soil Rating. From Testhole 07/12/02 5 min/in = 12 gal per sq.ft/day No. of Bedrooms 4 Required Area per Bedroom: 15011.2 = 125 sq.ft. Total area required: 125 x 4 = 500 sqft Testhole depth 16 feet Bottom Rock At 10 feet Top Rock At 4 feet Rock Depth 6 feet Minimum Trench Length 500 112 = 42 ft. Use 50 ft SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTI I 50 FT TOTAL WIDTII 2 FT TOTAL DEPTH 10 FT ROCK DEPTI I 6 FT COVER 4 FT SEPTICTANK 1250 GAL The installation of this septic system will not prevent wells and septic systems from being installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. 1 ♦ 1 ♦ I 1 ♦ 1 /1 S_ SX UP STAN\50 ARDCAL AW sTsl[yTMOCH SCALE, j' = 50 a AVAED IUV.. /00.00 iT I205 AK 99501 M DESIGN NUf f I I LOT 6 BLOCK GARY SCHWARZ DALZELL DALMU fNE1TER SSD I I DAM 2/316 8200ANCID 2537 I PERMIT # SV02OXXX PID M 015-291-18 D-S02062.DW6 F - - ---F - - 7 1 i 1 I 1 t / / VACANT oil op I 4 2 N 3 \ r o sa /oQ tso tar 250 3Al II •�� SEPTIC AREA SCALE, Q' = 100 FT. HILROB AVENUE 10,Y&N SYUKKLANU Y.L.I I LOT 6 BLOCK 2 DALZILL—SCHNEIM SID I I SEPTIC SYSTEM DESIGN 203 W 157H. AVENUE GARY SCHWARZ DATE: JULY 16, 2001 (9071 279-3916 (NCH. AK. 99501 5613 DALZELL CIRCLE SHEET. 1/3 GRID: 2537 PERMIT # SV020XXX PID It 015-291-18 B-S02061.DVG TO EXIST. Iffiv I O O _O H � O 1250 gal Septic tank o c c Cu m v v e � o o 'o A 3 t2 Standard Trench, 2' Vide 50' Long 10' Deep 6.0' Sewer rock 4' Cover ••••� QF ����♦ ��` ♦♦i :. 49th 0 i.... ♦ �`;• TOBB N SPURKLAND ♦.r °• O. CE -2223•• .•'.�+i ♦ • NO SCALE W# k49 .ffE..... •.•• Monitor Cleanouts 4' Cover Silt Barrier 6 ft of Septic Rock 1250 gat septic tank Effective ND SCALE TOBBEN SPURKLAND P.E. LOT 6 BLOCK 2 DALZELL-SCIINEITER SEPTIC SYSTEM SCHEMATIC 203 W15th Ave GARY SWARZ DATE, JULY 17, 2002 Anchorage Ak 99501 56TJ aA1m CW= SHEET 3/3 GRIDS 2537 PfRAI/T SWO20OXX PARCEL ID 1015-291-18 D-S02063.OWG Performed Fcr. Leval Description: Depin 2- 7- (ENGINEER:S SEAEI- . .L s .TT 12 Soils Log - Percolation Test n / C • e J Date Performed: ' �� 2 /tl 7 _� �,y�jQwnsnip, Range, Section: Slgpe 4) Site Plan WAS GROUND WATER Ci tA,,..L gnM.1� ENCOUNTERED? Municipality of Anchorage Gross Time Development Services Department IF YES, AT WHAT DEPTH? Building Safety Division y 0 On -Site Water and Wastewater Program Y�EP 4700 South Bragaw St. -7// o L P.O. Box 196650 Anchorage, AK 99519.6650 \ wwwcianchorage. ak.u5 �— (907) 343-7904 Performed Fcr. Leval Description: Depin 2- 7- (ENGINEER:S SEAEI- . .L s .TT 12 Soils Log - Percolation Test n / C • e J Date Performed: ' �� 2 /tl 7 _� �,y�jQwnsnip, Range, Section: Slgpe 4) Site Plan WAS GROUND WATER Ci tA,,..L gnM.1� ENCOUNTERED? Date Gross Time _N0 s IF YES, AT WHAT DEPTH? L �I� S w Depth to Water After 0 hloniloring7 Y�EP 17.1 1 VlOTTC LI,( 1S. 0 F IADt,t 19-I 20 CO"'tENTS Dale-- /e_ -Maa: b9^ Date Gross Time Net Time Depth to Water Net D•co r-; I l 'PA4 Oa -7// o L 3/ loss lO.e,. t r b / /i7 S r a//3' 10 L 4 z .iz. uvni iuwr It -21ti tft�rn) PER' HOLE DIAMETER LPP Z.''///v TEST RUN eETWEEN 15 FT AND FT PERFOR4!ED BY. TS I "FS CERTIFY THAT THIS TES I PER=CP, !ED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE. 7 /;Z49 Z, r i MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION �\ 825 L Street - Anchorage. Alaska 99501 Telephone 264-4720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME TTnI-� ' / lLi^Q A4"( l PHONE 349- 1x58 I NEW ❑UPGRADE MAILING A DRESS / N /&-x /78Cp - R LEGAL DESCRIPTION L & 6 510 LOCATION ,V - NO. OF BEDROOMS O Y DISTANCE TO: Well f, /UU 11"` Ab prpyon area Dwell g� '� PERMIT NO. 2Q W Manufacturer Me I No. of compartments w Liq.Opacity in gallons / .� IF HOMEMADE: Inside length Width Liquid depth d Y JV2 DISTANCE TO: Well Dwelling PERMIT NO. Z?FQ- Manufacturer Material Liquid capacity in gallons W = DISTANCE TO: / Well/OO -F Founp�s b n d P. Near of n PE �y1IT ryp D lo r E F ? W No. of lines I Length of acl+ line Total le t o lines Trench width z Inches Distance between lines c H p Top of tile to finish gr e/ Materiel beplay, the inches Total effective absorption area W t7 Length Width Depth PERMIT NO. i F W fl Type of crib Crib tliemeter Crib depth Total effective absorption area DISTANCE TO: Well Building foundation Nearest lot line J J Class Depth Driller Distance to lot line PERMIT O. W � DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER '— PIPE MATERIALS D30 - 5 SOI L TEST RATI NO ISo a o INSTALLER 1 % REMARKS I00 '-l`- I { - APPROVE APPROVED 1� DATE LEGAL 6 - aa- 78 72013 (Rev. 3/78) ri I_I r -a I C I F• t L I T `— Cl F t=i r4 - H ;=1 U E DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 'L' STREET, ANCHORAGE, AK. 9'_:�501 264-4720 Dn2 �..,g L ` LZ• WELL FItJCs ��t�t—E I TE EF JEF: F EFM I T PERMIT 140. C 78010_• > �O ' � I , c�sfi. APPLICANT STEVE PIIDD SRA BOX 1786-R, 345 125=; LOCATION DALZELL CIR. LEGAL L5 B' DALZELL SID LOT SIZE 52000 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MA:'IMUM NUMBER OF BEDROOMS = 4 SOIL RATING C50 FTIBR)= 150 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: C•EF -rH= 12�: L_E"'3-F"= 4 CiF F i'v EL_ C•EF -r"= r 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). FEC!LI I F:EC• tL,-EF•T I C-r"r4F-: -. I OtiLLslraS~ PERMIT APPLICANT HAS THE RESPON'=IBILITY 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. --- -IF WCl C �- > I r-d-•F'ECT I Clr-d= FIFE FEG!I_I I FEVs --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT I -JILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL; OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC I -JELL. WELL LOGS ARE REQUIRED APJD MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATION'S AND CON'=TRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F'EFM I T EXF' I FE-. C•EC-EMFE: EF M:1: ::L *D r :-D- I I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIR..EMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCCE IS REMODELED TO INCLU1- MORE THAN 4 BEDROOMS. -- --------------- APPLICANT STEVE RUDD ISSUED BY_A�0 V3. 0 a O SOILS LOG .\ MUNICIPALITY OF ANCHORAGE �/ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Yd" PERCOLATION TEST 1 Pouch 8850, Anchorage, Alaska 99502 276-2221 SOILS LOG — PERCOLATION TEST PERFORMED FOR: 61-e ams, �L'J�(�% �L DATE PERFORMED: 4--'e 51/' LEGAL DESCRIPTION: �` `•' v %�Y =� // ��� r SLOPE SITE PLAN 1 '1 IFEET) I Lam "/ gi J, 7/ ' 2 3 4 5 s 7 84 1 7;eF set -.7d //ti 9 /e. n s/e s 10 11 12 13-I I Ccl�✓S//'F_, SaV✓Id- 14 15 16 17 18 19 I WAS GROUND WATER ,/v L�---I' ENCOUNTERED? N O, P E 7 IF YES, AT WHAT.�._ _ . '-1._.�._. DEPTH? ._ _. .. Reading Date Gross Time Net Time Depth to Water Net Drop .3 jo 7 �-3f Z31i SZ.S� it S// L Zsf/l/j I ; II _ �Frclp-1—.- —A j _I I WAS GROUND WATER ,/v L�---I' ENCOUNTERED? N O, P E 7 IF YES, AT WHAT.�._ _ . '-1._.�._. DEPTH? ._ _. .. Reading Date Gross Time Net Time Depth to Water Net Drop .3 jo �-3f Z31i SZ.S� it S// Zsf/l/j 7��W1 014 ft •, 20 -{ I �7 ILEI PERCOLATION RATE / L (minutes/inch) r TEST RUN BETWEEN FT AND FT COMMENTS �' �S L, SY • �/3 iCr PERFORMED BY: (_ �'!� S !-• EL, % y CERTIFIED BY: `` �L 4at.�-� DATE:✓/ . 72008 (7/761 3� a(u� 44 35 D3o34 f4)ae oLZ6(4zj ea 3' / ST Dk 13f. q- Ad 4,LK 4 �R Ib4wreA Cl/ T KEN'S .'COMPANY WATER WELL DRILLING PUW SALES & SERVICE (907)243-7893 _ 3163LINOcn..R.Ve KEN JOHNSON ANCHORAGE, ALASKA 99502 b]arch 29. 1918 ' WATER .YELL LOG Steve Rudd Between 99th and 100th off Birch road ft. to 18 in. frost.. -,ravel and brown silt 18 in. to 12 ft. and brown silt ' ."ravel 12 ft --to 32 ft.' gravel and ;ray silt 32 ft. to 60 ft. brown silt with some !ravel - 60•£t. to 71 ft, fflacial till ( compact+d ) 71 ft to 72 ft. clean sand with medium Gravel" , " water bearing test bailed at 12 gallons per minute with no drawdown a clearing Static wader level 55 ft. Total casing 72.5 ' MUNICIPALITY OF ANOIORAOE Set hump at 71 ft. DEPT. OF HEALTH & " ENVIRONMENTAL PROTECTION " , 'JUN 51980 RECEIVED _ RETURN TO: Division of Geological and Geop'irsicai Surveys e 3001 Porcupine Drive • Anchorage, Alaska 99SOI c;tiat tV1wUrt:-1R1V1 STAPLE OR TAi-k WATER WILL R (CORD Drilling Company Namef�y 1 LOCATION OF YELL Drilling Permit Number OWNER NO. STATE OF ALASKA OEPAATMENT OF NATURAL RESOURCES Borough 'odivision Lot 3lock Fraction E 6 i Section No. Town x/S Range E/W Meridian Distance and Direction from Road Intersections Street Address and Are, of Wall Location 3 OWNER OF WELLt Address: 2 WELL LOG fes, bolo+ Thickness surface of material TyOe Too BOt[M itIaIVA 6 WELL DEPTH: (completed) ft, Sur/ace Clew tion Date I Completion ^ ? (k/ S Cable tool Rotary Oriven Dug ElAuger Jetted Bored El Mart 6 USE: omestic ❑ Public Supply 0 Industry _ ElIrrigation ❑ Recharge ElCommerolal ElTest Well ROOtther: 7 CASING: El Threaded Welded Height: Above 0 eelw Iy1 In. to eft. Depth surface ft. �In. to ft. Depth we lght Ibs/!t. Drive She,1 Yes a90 D FINISH OF VELLI Typo: g')1f/rn Diameter• a Slot/Mesh SIAe /4 A nth Set between �f a d It. Fittings: 9 STATIC WATER l[YEL•14: ft. 1:1 �beior land Surface Type of Measurement O''�r ! 10 PUMPING LEVEL bales land surface ft. after hrs. pumping g.p.m, ft. after hrs. pumping 9.0.0. 11 WELL HEAD COMPLETION: 13 In Approved Pitto Fittest Adapter 13 17" Above grade 12 GROUTING: Well Grouted: 0 Yes IytNO Material: El Neat Cement ElMarl 12 SANITARY: Nearest Source of Possible Contamination —Feet 01raction Type Well disinfected upon completion Elves WHO 16 pumpt (If available) MP Length of Crop Pipe —ft. capacity D.D.S. Type: ElSubmersible El Other. Jet EIRSCIProcating IS REMAARS: Elevation, source of data, water quality tests, etc. 16 WATER WELL CONTRACTOR'S CERTIFICATION: This mall was drilled under Ay Jurisdiction and this report Is true to the bot of my 4nwledge and belle!: 0.aq ate ad Buctness Na �f Contract Lice—S. Number Address: �.319 J i /� Signed:/ Date Aut norieed Aepresentative form O2-WVK , 4 UNIUF L UTY OF AmHORAGE o x Development Services Department - - Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-291-18-000 Expiration Date: Legal description DALZELL-SCHNEITER BLK 2 LT 6 Site address 5613 DALZELL CIR Anchorage AK 99507 Current property owner(s) FEDERAL NATIONAL MORTGAGE ASSO 12/11/2024 X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: a Original Certificate Date: 2/20/2024 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory X Arsenic Advisory Other COSA Approval_June 2022 MUNICIPALITY OF ANCHORAGE Development Services Department fes, J p P � �- .- / Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 01529118000 Complete legal description DALZELL-SCHNEITER BLK 2 LT 6 Location (site address) 5613 DALZELL CIR Current property owner(s) FEDERAL NATIONAL MORTGAGE ASS. Day phone 352-9325 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: 0 Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: 0 Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK:* Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 22 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed 0 Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ ,550 Waiver Fee $ Date of Payment COSA# ()SG 2y Ia26 Date of Payment Waiver # COSA Application—June 2022 COSA Checklist Legal Description: DALZELL-SCHNEITER BLK 2 LT 6 Parcel ID: 01529118000 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA 0 Well log is filed with Onsite (or attached) Date drilled 3/29/78 Total depth 72 ft Cased to 72 ft 0 Sanitary seal is functioning correctly 0 Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 6/28/23 Static water level at beginning of test 51 ft. Comments B. TANK DATA Measured operating fluid level in septic tank 50 Date of pumping 2/14/24 ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 7/23/02 ❑■ ALL standpipes present per record drawing Total measured depth from grade 10 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑■ Monitor tubes go to bottom of effective. If not, state depth into effective ❑■ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced 2000 gallons 6/27/23 date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficienci COSA Checklist June 2022 Well production at time of test 8+ gpm Water storage tank volume0 gallons Well disinfected for coliform test? ❑ Yes ❑■ No OR Coliform bacteria is Negative Nitrate 7.57 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L 0 Arsenic less than MRL (ND) Collected by NRim Eng. Date 12/11/23 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 6/28/23 Results g Pass Fluid depth prior to test 0 Water added 600 gal New fluid depth 4 in Elapsed time 30 min Final fluid depth 2 in in Absorption rate 600 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 72 Effective depth used 2 in Effective depth remaining 70 in in E. SEPARATION DISTANCES From Priva(e Woll on Lot to: (Please enter distances it less than required or if community well on lot) Septic TenklLA Station on Lot a 100' Q Yes if No i Community Sewer Ma n hole/C lea nDut > 100' ❑■ Yes if No ft F■ Yes N Yes if No Neighboring Tapp ? 100' ❑■ Yes if No ft Private Sewer/Septic Line > 25' Yes if No Absorption Field on Lot > 100' [�] Yes if No ft Holding Tank > 100' Yes if No Neighboring Absorption Fields > 100' ■1 Yes if No Water Service Line ? 10' Animal Containment > 50' Yes if No n■ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑■ Yes if No = ft ■❑ Yes if No F-1 NIA — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q Yes if No i ft Surface Water > 100'■❑ Yes if No Tank to Property Line > 5' F■ Yes if No ft V'Vells on Adjacent Lots: Field to Property Line 10' ❑■ Yes if No ft Private Wells > 100' ■ Yes if No Water Main > 10■ Yes if No ft Community Wells > 200- ■1 Yes if No Water Service Line ? 10' ❑■ Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS ft ft ft ft ft ft ft G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by mfr 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, indicates that the on-site water supply andlor wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm NcrthRim Engineering Phone 694-7026 Engineer's Printed Name _Steve Eng Date 114124 OOA Checklist June 2022 OF Ar ,... .. .. Steve Eng W NCE -6256 'F AV \4 /i5/� MviMHOC P U T V OF ANC HOG A OE DEVELOPMENT SERVICES DEPARTMENT On -Site Water and Wastewater Section www.muni.org/onsite Septic Tank Advisory Certificate of On -Site Systems Approval # OSC241026 Subdivision: Dalzell-Schneiter Block:2, Lot: 6 907-343-7904 Fax: 343-7997 The septic tank for this property is 22 years old. The average life of an asphalt coated steel septic tank is 20 years. Typical replacement costs are $10,000 or more, not including engineering, surveying or MOA permitting fees. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. Nitrate Advisory Certificate of On -Site Systems Approval # OSC241026 Subdivision: Dalzell-Schneiter, Block: 2, Lot: 6 A water sample revealed a nitrate concentration of 7.57 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. ge, Alaska 995.9 6650 *www muni arg From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. -k Nlailmg Address P.4O Box 196650 *Anchorage; Alaska 99519 6650 * www muni org N 89057'00"E 230.00' 10 UTILITY EASEMENT ----------------------------------- m —_—_ a S6 FN�fF�NLY BLOT1t RET. 1B LJTSL.V ES� L n 3 ' N 86°00'00-E 0 m co N c M . OF A..1, ."49 TH*Ai .............................. s SHANE A. HOLT ,* 's LS -6914 a� 0 s � SAG AS -BUILT SURVEY SCALE: 1"-401 f1A1 %GLL_A,rIRV`E—I I�TGAG E5 INSPECTIONTHAT OF THE FOLLOWING EBY CERTIFY I HAVE PERFORMED A LESCRIBED OT 6. BLOCK 3 E DALZELL. SCHNETTER SUB. THE II,O TK,N HEREON W FOR THE USE OF UM,,, SSTITVIIOHB SPEdFKALLY TO &HOW ANY COKUCTS BETWEEN ANCHORAGE RECORDING DISTRICT. ALASKA AND THAT IIBL HEREON E ENTSLINES E%ISTWO STRUCTURES A I ATTER LOT LRES OR EASEMENTS AND E NOT TO BE USED FOR PDSrtgWNG AOpTDNAL PMPROVEl ANDTWISITUATEDT WITHIN VI BLE STRUCTMEB OR FEWALSEB. ENCROACHMENTS EXIST OTHER THAN NOTED. EASEMENTS OF RECORD. OTHER THAN THDSE SHOWN ON THE RECORDED PUT, ARE NOT SHOWN HEREON. HOTE ANY FENCELSEB SHOWN ME LOCATED APPROXIMATELY AID ARE NOT TO BE USED TO CETERMNE PROPERTY LINES DATEDALASKA THIS �BTH� DAY H 2008 T. OR LOCATE STRUCTURES —MARCORAGE. NOL. LL —MARC SURVEVI 1071J, FB IJ1J8 ANY PAVSO BID'MM MAY BE APPROXRAATE DUE TO SOW CONDRHD/B TEL. 345-5513 Municipality of Anchorage Development Services Department Building Safety Division On -She Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519.6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D._ 015-291-18 1. GENERAL INFORMATION Complete legal description Dalzell-Schneiter Block 2 Lot 6 Location (site address) 5613 Daizell Circle, Anchorage Current Property owner(s) Dadan Atkinson COSA# MOOgB Expiration Date: Mailing address 5613 Dalzell Circle, Anchorage, AK 99507 Lending agency Mailing address Real Estate Agent Mailing Address Day phone Day phone Kyrisia Price / Dynamic Properties Day phone 250-8756 3111 C Street, Suite 100, Anchorage, AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well ✓❑ Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site ✓❑ Individual Holding Tank ❑ Community On-site ❑ 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 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 Cerfificate of OnSfte 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 Watkins Engineering, Inc. Phone 907-349-1851 Address PO Box 1111443. Anchorage, AK 99511.0443 Engineer's Printed Name Cindy W. Ellis Date �--17- 0s 5. DSD SIGNATURE Approved for 14- bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory _ Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: (Rw 11M) Municipality of Anchorage Development Services Department \ Building Safety Division Onsite Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519.6650 www.muni.org/onsde (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Dalzell Schneiter Block 2 Lot 6 Parcel ID: 015-291-18 A. WELL DATA Well type Private If A. B, or C provide PWSID # _ Date completed 3/29/78 Sanitary seal (YM) Yes Total depth 72 ft. Cased to 72 ft. FROM WELL LOG Date of test 3/29/78 Static water level 55 ft, Well production 12 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 9.01 mg/L Arsenic: ND mg/l Date of sample: 4/07/08 B. SEPTIC/HOLDING TANK DATA Well Log (Y/N) Yes Wires properly protected (YIN) Yes Casing height (above ground) 17 in. AT INSPECTION 4/8/08 52 ft, 5.4 9.p -m. Other bacteria 0 colonies/100 mL Collected by: Rocky Trainor / Watkins Engr Tank Type/Material Steel Septic Tank Date installed 7/23/02 Tank size 1250 gal. Number of Compartments 2 Cleanouts (YM) Yes Foundation cleanout (YM) Yes Depression over tank (YM) No High water alarm (YM) NA Date of pumping 4/8/08 Pumper _Northland Pumping, Inc. C. ABSORPTION FIELD DATA Date installed 7/23/02 Soil rating (g.p.d./W orft2/bdrn)1.2 System type Deep Trench Length 50 ft. Width.2 ft. Gravel below pipe 6 ft. Total depth 10 ft. Eff. absorption area. = f? Monitoring tube Yes Depression over field No Date of adequacy test 4/8/08 Results (Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 0 In. Water added2630 gal. New depth 2.5 in. Elapsed Time: 15 min. Final fluid depth 0.5 in. Absorption rate >= 600 g,p,d, Any rejuvenation treatment (past 12 mo.) (YM 6 type) None known If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 30 Building foundation 20+ Water main 100'+ Water Service line 50+ Surface water 100'+ Driveway, parking/vehicle storage 50+ Curtain drain none known Wells on adjacent lots 1004 F. COMMENTS: presoak conducted In conjunction with test. House vacant since February. 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 Cindy W. Ellis, Wa0ins Engineering. Inc. Date 4117/2008 COSA Fee $ U__�6 4 Date of Payment 4/1:7 /a Receipt Number LDS j3� (Rev. 11/05) Waiver Fee $ 111Y W. Ellis, CE.1os77 _:4 I r Date of Payment Receipt Number D. LIFT STATION Date installed NA Size in gallons Manhole/Access (YIN) 'Pump on' level at _ in. 'Pump off" level at —in. High water alar level at in. Datum Cycles tested Meets alar 8 circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 104 On adjacent lots 100'+ Absorption field on lot 120+ On adjacent lots 100'+ Public sewer main 100'+ Public sewer manhole/cleanout 100'+ Sewer /septic service line 92 Holding tank N/A Animal containment areas 100'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation 10 Property line 50+ Absorption field 7 Water main 100'+ Water service line 35+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 30 Building foundation 20+ Water main 100'+ Water Service line 50+ Surface water 100'+ Driveway, parking/vehicle storage 50+ Curtain drain none known Wells on adjacent lots 1004 F. COMMENTS: presoak conducted In conjunction with test. House vacant since February. 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 Cindy W. Ellis, Wa0ins Engineering. Inc. Date 4117/2008 COSA Fee $ U__�6 4 Date of Payment 4/1:7 /a Receipt Number LDS j3� (Rev. 11/05) Waiver Fee $ 111Y W. Ellis, CE.1os77 _:4 I r Date of Payment Receipt Number 14 WiE�Al SCS Re LM 1081396001 Client Name Watkins Engineering Project Namd# Dalull Schncitel SD B2 L6 Client Sample ID Dalull Schncitel SD B2 L6 Matrix Drinking Watcr P%AISID 0 Sample Remarks: Ali Dales/17mes are Alaska Standard Time Printed Datelfime 04/16/2008 12:04 Collected Date/time 04/07/2008 14:20 Received Date/rime 04/07/2008 14:45 Technical Director Stephen C. Ede Allowable Prep Analysis Parameter Results POL Units Method ConminerlD Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 04/15/08 04/15/08 NRB Waters Department Total Nitratc/Nitritc-N 9.01 Microbiology Laboratory Colony Count 0 Total Coliform 0 Fecal Coliform 0 0.100 mg/L Sh1204500NO3-F B (<10) coUl00mL SM209222B coVl00mL SM209222B coVlOOrnL SM209222B 04/11/08 LCP 04/07/08 DLC 04/07/08 DLC 04/07/08 DLC Municipality of Anchorage • Development Services Department Building Safety Division ' On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.m=i.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 080098 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 2, Lot 6 of Datzell Schneiter subdivision. This inspection revealed a nitrate concentration of 9.01 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. N 89057'00"E 230.00' 10 UTILITY EASEMENT ----------------------------------- m —_—_ a S6 FN�fF�NLY BLOT1t RET. 1B LJTSL.V ES� L n 3 ' N 86°00'00-E 0 m co N c M . OF A..1, ."49 TH*Ai .............................. s SHANE A. HOLT ,* 's LS -6914 a� 0 s � SAG AS -BUILT SURVEY SCALE: 1"-401 f1A1 %GLL_A,rIRV`E—I I�TGAG E5 INSPECTIONTHAT OF THE FOLLOWING EBY CERTIFY I HAVE PERFORMED A LESCRIBED OT 6. BLOCK 3 E DALZELL. SCHNETTER SUB. THE II,O TK,N HEREON W FOR THE USE OF UM,,, SSTITVIIOHB SPEdFKALLY TO &HOW ANY COKUCTS BETWEEN ANCHORAGE RECORDING DISTRICT. ALASKA AND THAT IIBL HEREON E ENTSLINES E%ISTWO STRUCTURES A I ATTER LOT LRES OR EASEMENTS AND E NOT TO BE USED FOR PDSrtgWNG AOpTDNAL PMPROVEl ANDTWISITUATEDT WITHIN VI BLE STRUCTMEB OR FEWALSEB. ENCROACHMENTS EXIST OTHER THAN NOTED. EASEMENTS OF RECORD. OTHER THAN THDSE SHOWN ON THE RECORDED PUT, ARE NOT SHOWN HEREON. HOTE ANY FENCELSEB SHOWN ME LOCATED APPROXIMATELY AID ARE NOT TO BE USED TO CETERMNE PROPERTY LINES DATEDALASKA THIS �BTH� DAY H 2008 T. OR LOCATE STRUCTURES —MARCORAGE. NOL. LL —MARC SURVEVI 1071J, FB IJ1J8 ANY PAVSO BID'MM MAY BE APPROXRAATE DUE TO SOW CONDRHD/B TEL. 345-5513 L.5, Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. Of5-2q1- IB HAA # ` L-A0V, Expiration Date: 1. GENERAL INFORMATION Complete legal description 1-0 T bJR K 20 a LILZELL— Location (site address or directions) 5 13 0A L-Z.t=. t_X_ G tt7_CLt= Current Property owner(s) I XV0A f 4>T>2o N 6 Day phone _ 997-619-1 Mailing address 51o1'S bALZf:LL C_tr2,Lt_k7 Lending agency 1Y/ELLS EA'Q G 0Day phone Mailing address Real Estate Agent F S 'B D Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: '-4_ 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site R, 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 4 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. (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 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 ;T%be�-r !90V le hl_ Phone 17 -7&? -39/L7 Address go 3 1v% I >" A Zo 3 Engineer's Printed Name 5. DSD SIGNATURE _J,tnf� Approved for Disapproved. L bedrooms. 10 Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: A s / Original Certificate Date: (Rev. 01102) Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LOT to . U 2 D A LZk LL— S c"IA VZ % TtYQParcel lD: 015 — 2R 1-1 A A. WELL DATA Well type _K If A, B. or C provide PWSID # 3 Date completed a9 -7g Sanitary seal (Y/N) Total depth 7 L fL Cased to 7 L ft. Date of test Static water level Well production FROM WELL LOG 3Ia 417 h ft. 9— p.m- Well Log (YIN) Wires property protected (YIN) Casing height (above ground) �_in. AT INSPECTION 411Z 0oz Z— g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 ml. Nitrate 351 mg.A. Other bacteria colonies/100 /ml. Arsenic: mg.A. Date of sample: Collected by:! - Ie y e /= 1,t+ a+ B. SEPTICIHOLDING TANK DATA Tank Type/Material S2 L - c. sled Date installed Tank size IA60 gal. Number of Compartments o2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) 2;L_ Depression over tank (Y/N) _ti_ High water alarm (Y/N) Date of pumping 10 ZSl/o''5 Pumper A oa& d s C. ABSORPTION FIELD DATA � Date installed 7�3 e L Soil rating (g.p.dJft2 or felbdrm) 1• System type / 4444G �r Length t>0 ft. Width .2- ft. Gravel below pipe 4o ft. Total depth t 0 ft. Eff. absorption area j ftZ Monitoring tube Depression over field IA Date of adequacy lest 11 V. -el, o 1 Results (Pass/Fail) T�:' For -9 --bedrooms Fluid depth in absorption field before test —o—in. Water added gal. New depth fin. Elapsed Time: min. Final fluid depth— rate >= L 1�0 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes. give date '� D. LIFT STATION Date installed Size In gallons Manhole/Access (YIN) IX "Pump on' level _ in. 'Pump ofP lev at _ in. High water alarm I at in. Datum Cycles les d Meets alarm rcuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot !D3 On adjacent lots too Absorption Feld on lot 1, 5 On adjacent lots 1 fro t Public sewer main N/A Public sewer manhole/cleanout N/A Sewer/septic service line QD Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10 Property line 155 Absorption field 10 Water main rA/A Water service line Surface water N 1 o Wells on adjacent tots 10 D + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line SO * Building foundation 3 D + Water main 114/A Water Service fine Surface water a Driveway, parking/vehicle storage 5 el t Curtain drain µ ( o Wells on adjacent lots I� F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and E ••••w �' review of Municipal records that the above systems are in conformance with MOA HAA guidelines In effect on this date. Engineer's Printed Name l o b o _tj 4 en Q �• Date HAA Fee S Lf 30 Date of Payment Receipt Number (Rev. 12/07), Waiver Fee $ Date of Payment Receipt Number 3o.ae- r m ) % \le,4 r� A. 7 dl 417 OF A44111 G 0 :49TH Vol ....«..«.« . 50 tt'' N�L'4b .•: iO0N1 Karl pov9np ? •, ,/ �,G z� � L. cls � ��/ •: 1'S61.S �.•' � z-...� `.. NC1TF TN M w[fl—S NOT TO BE USED -FOR ANY GWMITTAL TO THE MUNICIPALITY OF ANCHORAGE. V_ _ _ 1 t j" ��� . It it the r:"mlbl:lty of the o-ner to uetermine ft - ex'stcax of any mcn'ents, covcnwt, or restrlclens xcr�• Lfrd 4o cA epps on :he recorded subdivision Plat. ��•r L'rdvno e(reumstaeea should ory ds;a,5crcen be L gAS)~�gCNTSOi RLCORD,Oj'HL•R`1iANTHOSC• ' and kr xaastraa:on or Lar estxb islinS bcunduy or SHOWN ON THE RECORDED hAT, ARL• NOT face fines. The sur•eyor taW rnpnmttility rat rte SHOWN H=. *ON. - InualImmcdonenly• I.F. •F.ND Z DRASSCAP MONUM" LOT_ _ BLCCK__Z_ 0lecNrlrc �s (PLL.TNO.:�• MAR CORNER FOUND ANCHORAGE MCOROI`IG DISTRI p HUD ANDTACK .s PItEPWD BY: I DOWLING 6c ASSOCIATES — t 1 1426 Hyder Strcct BY' � Anchorage, Alaska 99501 REVISIONS DATE BY� SCP LE: WORKORDE4 FIELD BOO., GAIDNO 'WMU tc •WN!2at• r3©Z SI eW • '7N Xdd• 5-24-041 5111PM1 SCS Retia 1042746001 Client Name Tobbcn Spurkland P.E. Project Name/fr 5613 Dalzell Circle Client Sample ID 5613 Dalzell Circle hlatrla Drinking Water Sample Remarks: 1907 55.530+ 21 2 All Datea/times am Alaska Standard Time Prleted DateMme 05/24/2004 14:11 Collected Date/time 05:19/2004 14:00 Received Date/time 05119/2004 15:26 Technical Director StphA C. Ede paramaar Resole PQL Units Mahod Container ID Allowable Prep Aaalytir Limits Date Dale [nil Nate:a Departxant Nitrate -N 3.51 0.100 mg/L EPA 300.0 B (<-10) 05/20:04 JIB Microbiology Laboratory Taal Coliform 0 aol,100mL SM139Z:2B A (<"i) 05/19,u4 DKC ov Municipality of Anchorage O Development Services DepartmentBuilding Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel l.D. 01,5 -,2 q/— I o HAA # YAO.:2,O 3 Expiration Date: _ / / _?, / - 0!2- 1. 2 1. GENERAL INFORMATION Complete legal description 4 0 4,.p 8 K';L iDAL7_i t-)- - S c- N N L!:- i T1= l2 Location (site address or directions) 5l 13 T)A1_ZC-LL Ci LCAc Current Property owner(s) &,A 121Y 50-5,AQ Z- Day phone Mailing address Lending agency Mailing address IP.0.'RoX A'3121.7, Day phone Real Estate Agent "I oRNVr i -e WVzb1 15 `� $� Ks -� Day phone 3 Z Mailing Address _& ch f 5 3 Unless otherwise requested, NAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY:' TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site 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 4 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. (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 Health AuthorityApproval 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 J We H Phone a—) •-5 171 L - Address 20 � r✓ I Engineer's Printed Name —L 5. DSD SIGNATURE Approved for Ll bedreoms. Disapproved Date a Conditional approval for bedreoms, with the following stipulations: I t rrrrrrr Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other By: �i�/ /r" • /f C=:jt Original Certificate Date: Q ' �2' /– O Z (Rev. 01101) c- Municipality of Anchorage Development Services Department Euilding Safety Division On-S;te Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-5650 www.a.anchcrage.ak_:.-s (907) 343-7904 �3• a,r CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O 16 -941 I -1 tt3 HAA # ht_5)-DB� Expiration Date: 1. GENERAL INFORMATION Complete legal description L-+7 j 6 gK 2 ALZ i -LL- SC Id Nj:=- I -r F, l2 Location (site address or directions) 25& t3 DAL.7-a1-t- C1 2-cL— L Current Propertyowner(s) GAa`t SC_PV-1AI2_Z Day phone Mailing address Lending agency Mailing address o. Sax X31222 _ Day phone Real Estate Agent 394a "A"'& tyle, �ci 115e_4�o 1v _ Day phone Mailing Address Ck o (C e- S k1. 3 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY:' Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site 9 Individual Ho!ding tank ❑ Community On-site ❑ Public Sevrer El The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an inde.pendent 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 bn-site wsstswat=_r disposal and!cr 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. (Certificates may be reissued for a period of up to one year wiih valid water samples.) Certificates are valid for one year for prepert'.es served by Class A or B wells cr a public water system. The Municipality of Anchorage is not responsible fcr errors or omissions in the professional engineer's work. r 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply 2nd/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 211 applicable Municipal and State codes, ordinances, and regu!ations in effect at the time cf, installation. Name of Firm_ lobi -e i vrk( % fes -L Phone a-7g-3�flb Address 6 �9-3 I.ty", eqUl il,4 t o 7� Engineer's Printed Name 5. DSD SIGNATURE Approved for Disapproved. X Conditional approval for bedrooms. _ Date7ho'Z— .� .•er i✓ueY 4 bedrooms, with the following stipulations: Original Inspection Report documents stamped and signed by the engineer must be delivered to this office by 9-8-02, along with completed Health Authority Approval checklist sheet. HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: �� %L�. %' w Original Certificate Date: 53 - 8- 0 Z IR«. n!r-y Municipality of Anchorage Development Services Department Building Safety Division Onsite Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LeTG� �k 9-+ •DALZeLL- 5;c-4 WIZITarLParcelID: X15-2g1-1f� A. WELL DATA Well type If A, B, or C provide PWSID #�q Well Log (YIN) _ Date completed !4,1/7, Sanitary seal (YIN) Wires properly protected (YIN) Y Total depth 7 z ft Cased to iL ' fL Casing height (above ground) Aq n. FROM WELL LOG AT INSPECTION ` V7, 9/7 bl `0/0 z Date of test Static water level F; Z; ft. `>' ft Well production'L- g.p.m. Z- g.p.m.' WATER SAMPLE RESULTS: Coliform colonies/100 mi. Nitrate mg.A. Other bacteria W/o _colonies/100 ml. Arsenic: �mg.A. Date sample: r- Collected by: of B. SEPTICIHOLDING TANK DATA Tank Type/Material Jr i r� SA'0 1e'r Date installed Tank size /Lt2 gal. Number of Compartments 2 Cleanouts (YIN) y Foundation cleanout (YIN) Depression over tank (Y/N-) t4 High water alarm (Y/N) Date of pumping N/A Pumper C. ABSORPTION FIELD DATA „7 / Date Installed /J13/0 Soil rating (g.p.d./ft' cr =>t- bd;m) /. 2L System type Length SO ft L5 Width " 7 ft. 15, Gravel below pipe 6 R Ls Total depth to ft Eff. absorption area /o ! ft Monitoring tube Depression over field f` Date of adequacy test t4 A- Results (PasslFail) 0720 For V- bedrooms Fluid depth in absorption field before test of Water added gal. New depth✓✓n. Elapsed Time: V/min. Final fluid depth ✓n. Absorption rate >= "� g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) t/ If yes, give date D. LIFT STATION Date installed 'Pump on' levet at_ in. Datum E. SEPARATION DISTANCES Size in Manhole/Access(Y/N) 'Pump9K' level at —In. High water alarm level at tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 105 - On adjacent lots 1"4 Absorption field on lot On adjacent lots I n -o I Public sewer main Public sewer manholelcleanout NSA Sewer/septic service line q a Holding tank N�A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation I D Property line I Vt7 Absorption field le 5), Water main N/A Water service line Surface water r't / O Wells on adjacent lots t fJ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line { C V Building foundation J5V Water main Water Service line11 D Surface water ")10 Driveway, parkingNehide storage Curtainrdrain N ! D Wells on adjacent lots _164-0 4 F. COMMENTS 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 HAA guidelines in effect on this date. Engineer's Printed Name ! eq 4 be a1 �p � r V l aK.Q Date W HAA Fee $ n5 Date of Payment Z Receipt Number (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number In. AK CUE Environmental Services Inc. Cr&E Ref.# 1024465001 Client Name Tobben Spurkland P.E. Project Name/# 6/2 Dalzell-Schneider Client Sample ID 6/2 Dalzell-Schneider Matrix Drinking Water Ordered By PWSID 0 All Dates/Times are Alaska Standard Time Printed Daterrime 07/23/2002 14:48 Collected Date rime 07/18/2002 13:00 Received Date/time 07/18/2002 14:00 Technical Direector^Stephe de ` Released By ; Sample Remarks: Allowable Prep Analysis Paramos Results PQL Units Method Limits Date tate Init Waters Department Nitrate -N 3.43 0.200 mg/L EPA 300.0 (<10) 07/19/02 JDT Microbiology Laboratory Total Coliform 0 col/100ml. SM189222B (<I) 07/18/02 KAP 0 LL 0 E 9 C, 0 A C S rvVe� l 1T L7$ x 19_ '7 t to • /v'v� esu. =F- b — _ E. —9— r—.4 S— 1�OF At. P ............. .. .. r, t; lamas Karl Dowling ' o s •�. 15615 , • � ,. 1lt� AortsSIONA�� � It is the responsibility or the owner to determine the existence orally easements, covenants or restrictions - which do not appear on the recorded subdivision plat. N9IL5. . Under no circumstances should any data bacon be A S BUILT EASEMENTS OF RECORD, OTHER THAN THOSE n used for construction or for establishing boundary or SHOWN ON THE RECORDED MAT, ARE NOT . fence lines. The surveyor takesresponsibility for Ole SIiOWN HCREON. initial transaction only.' 1.F.iaEL1l2' LOT__Ko BLOCK!— m IRONASS PE MONUMENT PLAT NO.: O IRON R C � —, • RL•DARCORNC•RFOUND ANCHORAGE RECORDING DISTRI 0 HUD AND TACK PREPAVD BY: DOWLING & ASSOCIATES 1426 Hyder Street Anchorage, Alaska 99501 t DATE: BY: SCALE: ✓u 1"=-5 REVISIONS WORK ORDER: DATE BY FIELD BOOK: GRIDNO.: JUL-a.7-2UJZ 12:44 PM T 6PURKLr.141) 9U7 270 eU13 T. SPUMLAND P.E. WEST IYM. AVENUE SUITE 203 ANCHOKAOE. ALA-SXA 995M-3906 (907)379.3916 Fu (90T)-2766013 RESIDENTIAL WELL INSPECTION LEGAL: Lot 6 Block 2 Delzell-Schnsiter SID OWNER: Gary Schwarz LOCATION: 5613 Dalzell Circle TYPE OF WELL: Private. Single Family WELL LOG AVAILABLE: Yes INSTALLATION REQUIREMENTS MET: Yes WAIVERS GRANTED: None WELL YIELD FROM WELL LOG: 12 Gallons per Minute WELL YIELD FROM TEST: 6Gallons per Minute DATE OF INSPECTION: June 20. 2002 TEST PROCEDURE: Well was Pumped at a constant rete while the drawdown was monitored with an acoustic probe. At the beginning of the test wan level was found at 54 fat ftom the top of wing. At a pumping rate of 6 gallons per minute the weer level stabilized at 59 %cL A total of 350 galloon was pumped In a time period of 60 minutes. The well recovered to 54 in 4 minutes. TEST FOR E.COLI AND TOTAL NITROGEN: Well was tested for E.Coli and total nitrogen on Julu 13. 2002 RESULTS: E.Coli 0. Other Batt" ND Total N':trate-N 3.430g4 Max. allowable Total Nitrate -N IOMBI. 10 Colonies of Bacteria Allowed TEST RESULTS: This water quality of this well meets the mquiremam of the Municipality of Anchorage. The Municipal requirement for well flow is ISO gallons of water per bedroom per day. This well exceeds this requiremant. The assessment of the condition of the well applies only to the conditions as of the day tested. The flow rate may change due to subsurface condition that may not be observed from the surface, and changes In the land use and other factors that may impact the aquifer feeding the well. (1• 3 T 1 P. k)-. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services TAL SERVICES DIVIS.- On-Site Services Section P.O. sox 196650 Anchorage, Alaska 99519-6650FE6 0,) 1998 343-4744 CERTIFICATE OF HEALTH AUTHORITY RECEIVED APPROVAL FOR A SINGLE FAMILY DWELLING Parcel l.D. # 015 - 291- 1 £l V HAA # V\L06, 4Yl I L 1 GENERAL INFORMATION Complete legal description 12AIMZ L— SCHNIFI71_ O $b< a LoT b Location (site address or directions) 5L 13 DA L Z ff LL c - Ira Gi E Property owner R ()1pD S l E t/ LE Day phone Mailing address ?_Q FOX II,�1 1 7 '54% Lending agency _PA t! it � r`11re-r 1 4 L/A5 Day phone Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: _ L_ 3. TYPE OF WATER SUPPLY: Individual well Community well Public water Day phone NOTE: If community well system, provide written confirmation from State ADEC attest - Ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: j Individual on-site v Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. naa(Rw wi) Fwt uoAm 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 furtherverifythat based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system Is in compliance with all Municipal and State codes, ordinances, and regulations In effect on the date of this Inspection. Name of Firm Address 40 Z W / j A( Engineer's signature 6. DHHS SIGNATURE v Approved for 'r��%� bedrooms. Disapproved. Phone- P-79-3 9/(�_ Date Conditional approval for bedrooms, with the following stipulations: Additional Comments 0 Date 0.1Z -C28 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 purchasersof homes and their lending institutions in orderto 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 engineers work. >Z�=M" Vit) Back uWm -'v MCNIAL 56RVICES DMS,. FEB o,5 1998 Municipality of Anchorage RRVICES V E D 1 DEPARTMENT OF HEALTH & HUMAN SE Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: QAL.ZIL L -L- Sc l -a t-1 C ITta- iL Parcel I.D.: O f 5 — A-ql - / A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number P4 //I' Log present (Y/N) Date completed 31ag 1-7 t( Total depth 791 Cased to 7V- / Casing height (above ground) I Sanitary seal (Y/N) . FROM WELL LOG Date of test ?'/a4/79 - Static water level 0 Wires properly protected (YM) AT INSPECTION '/ag %g s- 63 Well production 102 g.p.m. — g -p.m -WATER SAMPLE RESULTS: % Coliform / Nitrate 5,7q �`� Other bacteria D Date of sample: / o�tl iij Collected by: �- S B. SEPTIC/HOLDING TANK DATA Date installed ' 7 Tank size 1A 519 Number of Compartments Z Cleanouts (Y/N)—y6, Foundation cleanout (Y/N) 'V Depression (Y/N) . `l High water alarm (Y/N) Date of Pumping �'��� Pumper kiAotoS-?use �t'SS,iJcb\ C. ABSORPTION FIELD DATA Date Installed s 7 Soil rating (g.p.d./ft2 or ft'/bdrm) System type C -L, Length y9 Width 4.5 Gravel thickness below pipe _Total depth Effective absorption area Monitoring Tube present (YM) ty/ It over field (YM) Data of adequacy test Results (Pass(Fail) For /I/ bedrooms /-A it Fluid depth in absorption field befo a test (�n.); Immediately after 70 gal. water added (in.): Fluid depth — (ins) Minutes later: ! r< Absorption rate, _ C e -L7 g.p.d. Peroxide treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96). �( r� /7r; ✓acr xeK% �o �� S .* D. LIFT STATION Date Installed Manhole/Access (Y/N) High water alarm level at* _ Cycles tested E. SEPARATION DISTANCES Size In gallons "Pump on" level at' 'Datum SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off" level at' Septic/holding tank on lot 0 2- On adjacent lots Absorption field on lot IAC + On adjacent lots >i w, r Public sewer main WA- Public sewer manhole/cleanout N1-1 Sewer /septic service line > 5 D Lift station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation % Property line > /C / Absorption field % Water main/service line ;� YO Surface water/drainage t'� o Wells on adjacent lots /&-o SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line _i !O Building foundation a.61 Water main/service line 5o r Surface water /'V/O Driveway, parking/vehicle storage area > S'o Curtain drain M/d Wells on adjacent lots >> loe--) F. ENGINEER'S CERTIFICATION �-"•�`^ I certify that I have determined thru field inspections and review of Municipal records'th'at the above systems are In conformance with MOA HAA guidelines in eeffact on this date. Signature Engineer's Name P4, c,72, Date 3 et7 HAA Fee $ �` Date of Payment Receipt Number Q 35e V 72-026 (Rev. 3/96)' Waiver Fee $ Date of Payment Receipt Number MUNICIPALANCHORAGE • DEPARTMENT OF HEALTH &HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # [ilia - 09 1- 19; HAA # 1.1 (VISO 11 S 1. GENERAL INFORMATION Complete legal description _go#6. Cfccrc 2- Dalzefl- Sct,neiFe,- Location (site address ordirections) _ 5613 Do(z&I( Circ (e Property owner S b ve Rudd( Day phone Mailing address P•o. (30 Y, If173N" Ane6o-earl 4k 993-1! Lending agency SectFile Mo" -k 5y P_ Day phone 1-0 -5-626 Mailing address S-60 6 3 Y "' A -p- /Iz CAO!22l�eO /i k 993- 03 Agent N!rv� .A. C nec+nce� ✓Day phone Address Unless otherwise requested, HAA will be held for pickup. Peck "p 6y bw4 p- 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site � Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 22-025(R". V91) Fm l MOAM21 5. 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 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 furtherverifythat based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm F Ia F Fop 7-PrAprlaf Sew, Zvi Phone 3 H.r- l35_S Address I457!0 Ec/io Sf.7 A Ak 995 'l� t Engineer's signature �" zt'-� 14� Date 3 / IS -193 Or AQ 0+ t Com••••..• n {' A �•� f 0 :•�,r�TFI ..............q1t........ • e �' �,. " `. �` ............;... 0 I wi THc'O�Oa: F. MOORE•; t b ••,• Cc - 3589 + 6. DHHS SIGNATURE /_ Approved for - bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Aft ionalComments Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It is suggested that a nerindir tenting he lerformed to insure the wells continued suitability. Nitrate concentration is 5.55 mg/1. EPA 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. 72-M(P.1/91) Bauk MOA921 Municipality of Anchorage AUL Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: P Z Da f Leff -S54 n et Le SID Parcel I.D. A. WELL DATA Well type rr;va Fe If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed 3/29/7 & DrillerI'ce^4t CG"'/0 Total depth 7 2 Cased to 7 2 Casing height 16- " Sanitary seal (Y/N) Wires properly protected (Y/N) t' FROM WELL LOG AT INSPECTION Date of test 3 /29 / 7 Fr 3 / rr 193 Static water level -- rn o 0 i* Well flow 129.p.m. S-. 1 t g-p.c") -. r Pump level 71 > 5'7 Peel- Cago ` SEPARATION DISTANCES FROM WELL TO: rn w t� Septic/holding tank on lot 100, ; On adjacent lots > roo'y m z Absorption field on lot I t h " ; On adjacent lots > too ' Public sewer main N. A Public sewer manhole/cleanout N.A. Sewer service line 90' Petroleum tank _NLoe e s e c0 WATER SAMPLE RESULTS: Coliform O cul /ruo m Nitrate •ss !'7I -e Other bacteria 10colbcoom Date of sample: 4/10/93 Collected by: TecR Svc B. SEPTIC/HOLDING TANK DATA Date Installed 6/ Z Z/ 7 8 Tank size I Z sb as I Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(Y/N) Y' Depression (Y/N) IV High water alarm (Y/N) Date of pumping Alarm tested (Y/N) N. A - Pumper fir« uu SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 100' On adjacent lots > 100' Foundation 7' Topropertyline 'tp, Io' Absorption field 7, Water main/service line >25' Surface water/drainage > roo' 72026 (Rev. 7M) Front CONTINUED ON BACK PAGE C. LIFT STATION N • A Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer = Manhole/Access(Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface water Date Installed //2Z/7& Soil rating IS'o O `/gdn. System type 7—re,, c Length - Lf? Width 32 Gravel thickness Total depth 12 .!r, Total absorption area & G Cleanouts present (Y/N) Y Depression over field (Y/N) N Date of adequacy test -711119.7 :Results (pass/fail)l au for 3 bedrooms Peroxide treatment (past 12 months) (Y/N) Noe I2n o... e vF If yes, give date N. A. SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 116' On adjacent lots > ftio' Propertyline to To building foundation 2y' To existing or abandoned system on lot N. A. Onadjacentlots 20' Cutbank Non[ Water main/service line > tads Surface water r a0 ' Driveway, parking/vehicle storage area > 5'0' Curtain drain Noee Spon E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines In effect on the date of this inspection. Signature ,! - Engineer's Name Tl ,ea 4140ne r-- Date = Date -Murch fS /993 HAA Fee $ /� CTIA Date of Payment Receipt Number 2 SZC 72-M (p••. 791) tack MDA 21 A'C'S ti1�� •.!rl0 t . THEODORE F. A100H �• 9 t st••. CC -35,09 n}v Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE. ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561.5301 Chenlab Ref .1 :93.0960-1 REPORT of AVALISIS Client Sample ID :L6 62 CAL2ELL-SCHNEITER HOSE BIB Matrix : WATER Client Nene :FLATTOP TECHNICAL SAV Collected :01/10/93 B 09:20 hre. Ordered By :T.F. MOORE Received :03/10/93 ! 12:30 hre. Project Name WORE Order :63900 Ptolecti Report Completed :03/11/93 PWSIO :UA Technical Releasesedd ly By 1 L Q EN C. ,:S:H EDE Sample ROUTINE SAMPLE COLLECTED BI: T.F. M.00RE. Remarks: QC Allowable Extract Analysis Parameter Results Quel. Units Nethod Limits Date Date Init --------------------------------------------------------------------------------------------------------------------------------------- RITRATE-N 5.55 mg!l EPA 353.2/300.0 IO 03/11/93 MCE ........................................................................................................ Sea Special Instr•ictions Above UA - Unavailable See Semple Remrks Above NA - Nct Analyzed 0 - Undetected, Repotted value is the practical quantification limit. LT - Lass Ihen D - Secondary dilution. �± OT - Greater Than I."S{3S Member of the SGS Group (SociM6 G6ndrale de Surveillance) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 5 =116%_ 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) �1 LT 60 B� ' !�:)L7_El1- `N-Jer7g - �Lf?7> Location (address or directions) (b) Applicant Name Telephone: Home —M6— 7-'71L, Business Applicant Address r'� �;f f 117 :e -k Axjc JnfA[,r < ?,;,II (c) Applicant is (check one): Lending Institution ❑ ; Owner/builderF; Buyer ❑ ; Other ❑ (explain); (d) g Institution K d4u�, Telephone Address vua 1sC_ (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-Family.0' Multi -Family ❑ Other Number of Bedrooms P, i 3. WATER SUPPLY Individual WelIg Community ❑ Public ❑ Note:lf community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onslte,P1 Public 13 Community 13 Holding Tank 13 Note: tf community well system, must have written confirmation from the Stale Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 720260t,e41 r2- 5. ENGINEERING FIRM PROVIDINU INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION I As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this h. Authority Approval shows that the on-site water supply and/or wastewater disposal system is sale, functional and adequai, for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm J3 ^r �f 7 Telephone Address�n1^1/ncrt/ Date ,PSE OF A' N n in a yeah �A�\ r i c Ce ey S. Meyr;' Li", 6353 ••�� SCO h�"q ....... Ccc nkx'.' DHEP APPROV,A/�//,�_CJ� _ Approved for u2 -°re bedrooms by Approved Disapproved Conditional Terms of Conditional 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 Slate of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025( 1 1184) Gt • N,I;NICIPALITf OF ANCHOPA DIEEMlROP1,V4NTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) iir�Y G 7 I CHECKLIST - FEBRUARY 1984 2644720 REC��V ED Legal Description: �T �� rti e JJL?Etc �rntEr i�� rpD A. WELL DATA Well Classification F')�!rv4rz= If A. B. C. D.E.C. Approved (Y/N) *1 Well Log Present (Y/N) t �' Date Completed Yield /7 621" , Total Depth i2. S Cased to 7Z.4; Depth of Grouting _ &VA Static Water Level Ss- Pump Set At Casing Height Above Ground + pr Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Z� C__ - Depression Around Wellhead (Y/N:) Separation Distances from Well: To Septic/Holding Tank on Lot IQ's+ - ; On Adjoining Lots I(�r's * 1-r To Nearest Edge of Absorption Field on Lot IQQ+F- ; On Adjoining Lots 10c'- t� To Nearest Public Sewer Line To Nearest Public Sewer CleanouVManhole ._r f A To Nearest Sewer Service Line on Lot roo~ Fr Water Sample Collected by In zsr !E- M' F ''} Date Water Sample Test Results Comments 5E'5_A77A1tkfV0 'v/) -r- wrlu 7U-4 r IA( C -Lt. LCG s lv/�tYR SQtllliC 7t5mCi;'so LTS B. SEPTIC/HOLDING TANK DATA Date Installed Size LZSV U No. of Compartments Z Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N) t'!o Date Last Pumped Pumping/Maintenance Contract on File (Y/N) 6�IA ; for NJf Holding Tank High -Water Alarm (Y/N) A44i Temporary Holding Tank Permit (Y/N) tiP Separation Distances from Septic/Holding Tank: To Water -Supply Well /CY,� Fr To Building Foundation 7 FT To Property Line x F To Disposal Field 7 t"T To Water Main/Service Line Z—�+ Cr To Stream, Pond, Lake, or Major Drainage Course Comments -5,tr- 4n7UHP.7'? 1N5P.-_VC/v RJOPOM Page 1 of 2 72-026(11)84( C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata c �/a;t Type of System Design -rFLE Date Installed 1178 Length of Field 'Cr Width of Field 32 =^r Depth of Field 5 cr Gravel Bed Thickness '7 Pr Square Feet of Absorption Area h tin ;t= Standpipes Present(Y/N) Depression over Field (Y/N) Date of Last Adequacy Test &6 Results of Last Adequacy Test 4 Separation Distance from Absorption Field: To Water -Supply Well /Cb * Fr To Property Line 39- To S To Building Foundation 7_4f Fr To Existing or Abandoned System on Lot ^;!A ; On Adjoining Lots ni/A To Water Main/Service Line 'ZS ,Cr To Cutbank (if present) N 8 To Stream/Pond/Lake/or Major Drainage Course N 14' To Driveway, Parking Area, or Vehicle Storage Area �S-n QT Comments i*_i:- ATAI-CNE"O rtie, MT crnr0 Py,4eei!ZZN D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments — Dimensions Manhole/Access (Y/N) — 'Pump Off' Lev ent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA Check Permitted Bedroom Rating Against HAA Request •• I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date o1 this inspection. Signed Date Company Receipt No. arw 14!{51 Date of Payment Amount: $ 4, Page 2 of 2 72-026 111,94) MOA No. ��•OF,q`• q% %1 0 BESSE, Bees 6 POTTS ��Q •'• �'•.r''8 2220 EAST 88 AVENUE j', 9TH , ~ S•9kI// A.VC11ORAC0, AK 99507 .' ! 4 N.••.... N.N:.. •, ( 907) 349-6451 HATER UK= TEST 4% tion: Client's frame: Address: n Date: -5 Subdivision: Lot: (� Block: re) t 1I7tF A ry Pr S Tester: MjpP- Kit � Fp Initial Reading on Meter: (0 FrNA� 30 1 TIME GPM GALMIS G VOLUtm GAL=15 TOTAL VOLUME Mt -TET Rq ADrrJ& q. zz S - 9! 3. f zi S�IgO 9'. zq 4 1 35 - SSU e� q:A4 1 SS (, ,. 13 C7 "t, I 57a0 in! 17 1 _C;F3S•} leiss 4 '76 Stii3C� 4'7 S�•� = SrArc tFv� ' 3n S Nq q-zs 7. S P n .n C xrien S c 7. i STATK_ CFVEL DlOTPS: ercr3nction Rate.: 4..SS GP.t 24 -Hour CapacityE ,Gallcros .t OC(TS/,D e iron' %Ayz 7/rm�� 9,4,o-1.? 7i 15�ryrr ' MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT12 N DEPT. C: '.' NT ' -`LT' I & VIRON., .... 625 L Street • Anchorage, Alaska 99501 AL :CTION ST LO�ATION Q-- \` I ENVIRONMENTAL ENGINEERING DIVISION APR 6 i9ig Telephone 264-4720 FF (("' F II `,F REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER'F,Ul I1EE D DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allowten 110) days for processing. 1. P 0PEE`R'TY OWNER Q}iONE SINGLE FAMILY _ n I LING ADDHESS a o_ «3Y PROPERTY RESIDENT (If d-fferent I om above) PHONE S L(, R 3//q S 2. BUYER PHONE since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY MAILING ADDRESS 3. LENDING INSTI UTION�f ' PHONE IC give MAILING ADDRESS 9. REALTOR/AGENT PHONE MAILING ADDRESS tl nlElr�V 5. LEGAL DESCRIP�ON p � C� ' )-I - & ` ST LO�ATION Q-- 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS ❑ One ❑ Four El Other SINGLE FAMILY El Two ❑ Five ❑ M LTIPLE 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.) 8. SEW`AG—E` DISPOSAL SYSTEM eelfindividual/on-site, installation date ,7g INDIVIDUAL/ON-SITE" give JJ " If system is over two (2) years old an adequacy test is required ❑ PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) ; , ' ev�� THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: I 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER 1:1SINGLE FAMILY ❑ MULTIPLE FAMILY ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY II PERMITNUMBER ❑ INDIVIDUAL DEPTH OF WELL ❑ COMMUNITY DATE DRILLED a. EJ PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER ❑INDIVIDUAUON -SITE DATE INSTALLED ❑PUBLIC UTILITY Connection Verified INSTALLER ❑Septic Tank or ❑ Holding Tank Size: JrD If Tank is homemade SOILS RATING give dimensions: - TYPEOFTANK I, MANUFACTURER TOTAL ABSORPTION AREA MATERIAL A 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line ii 5. COMMENTS n APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY Title V"LEGAL DESCRIPTION 72-010 IRev. anal