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HomeMy WebLinkAboutMOUNTAIN PARK ESTATES BLK 7 LT 7Mountain Park Estates Block 7 Lot 7 #017-391-12 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 - · D~TMENT OF HEALTH AND HUMAN SE~ES . Environmental Health Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~m~ DISTANCES IAddreAs SEPTIC ABSORPTION TANK FIELD WELL Phone[st Permit No. No of Bedrooms WELL TANKS L ~ ~ ~ ~ N TYPE OF ~Y~TE~ ~ PRIVATE ~ OTHER (Identify) REMARKS: Municipal and State guidelines in eec on this date: ~ ?~3'. JU N~ 25, 1 ?; L HeallhDepa.mentApproval:-~ ~' ~~ Date.~--/~--S~ ~ . 72-013 (3/85} DEP, ,.)F N~TU~',L R£$OURE$ :ologicoI 6 GeOphylicoI Surveyi 8. CASIN~= ~ Th~e~de~ ~Welded Ia STATIC WATER LEVEL: [].o. o, ~'..,o. 14, REMARKS: */- } PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: LCY 7; ,~/¢.'7. /'1~,,.'1-~;~ "~-~¢.~L. Township, Range, Section: 2 3- 4- 5 6 7 8 9- 10- 11 12 13 14 15 16~ 17- 18- 19 20 SLOPE WAS GROUND WATER SITE PLAN ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth Io Water Alter Menilering? ~ 01~ Nc) Reading Date Gross Time /0 ~0 Net I Depth to Net Time / Water Drop /0 IO PERCOLATION RATE ~'~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~_.~ FT/~,ND ~' FT P'R~ORME~ .Y: ~ I ~~ C~RTIFY~:::S ~T WAS ~ERFOR. ~D IN ACOO.DANC, WITH ALL STAT~ AND MUNICIPAL GUiDELiNeS iN EFFECT ON THiS OAT~. DAT~: ~ , 72-008 (Rev. 4/85} .G FFF_. 'PLA-hi L,~ ~.~/ NO V-.,'E LL$ o I HoNIT'o¢. 6RIE R ANCHORA6E AREA BO · Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: MAILING ADDRESS rF,~'~ /~'~'~/:Z/ LEGAL DESCRIPTION DISTANCE FROM WELL /Z~/ MANUFACTURER~_/.~ MATERIAL NUMBER OF COMPARTMENTS / INSIDE LENGTH INSIDE WIDTH ~ LIQUID DEPTH ~ LIQUID CAPACITY ~/~ GALLONS. SEEPAGE PIT: NUMBER OP PITS LINING MATERIAL ~ BUILDING FOUNDATION ~ ADDITIONAL ABSORPTION DIAMETER '/'~/ OR WIDTH-'fi/, LENGTH , DEPTH /~ CRIB SIZE: DIAMETER~ DEPTH DISTANCE FROM: WELL ~d,~.~', TOTAL EFFECTIVE NEAREST LOT LINE~ . ABSORPTION AREA (WALL A~A) 7~ SQ. FT. WELL: ~.~'//M~d ~'-~ CONSTRUCTION ~/~//-/~ DEPTH -- DISTANCE FROM: TYPE BUILDING NEAREST ~.~/~ ~z'~ NEAREST SEPTIC SEEPAGE FOUNDATION /g /~' LOT LINE /~ / SEWER LINE /~'-f TANK , , SYSTEM CESSPOOL -- OTHER SOURCES .,,'~g~ ~'~z-~,~f-/ APPROVED DISAPPROVED REMARKS DISTANCES: -~'//~ INSTALLED BY: ~///~ ////~ PIPE MATERIAL: LOT SLOPe: ~M~-~ '~ REMARKS: ~-.~,~Z/~, /..,'~'~ /~ Form NO. EQ-031 DIAGRAM OF SYSTEM DATE ~'~-~ ./~/¢7/z' APPROVED GreaTEr ANCHOrAgE ArEa BOrough IDE:PARTMIENT OF £NVIRONMENTA~;~C QUALITY SEWAGE DISPOSAL SYSTEM -- APPLICA~IDN AND PERMIT TYPE AND SiZE OF FACILITY TO ~E UERVED ~ ~,~,a{¢5'~''/ PERMIT NO PHONE FOUNDATION TO SEPTIC TANK ,~- ~' FOUNDATION TO SEEPAGE PIT ( SEPTIC TANK fO SEEPAGe PIT WALL SEPTIC TANK W . SEEPAGE PIT --~ DRAIN FIELD TO NEAREST LOT LINE. WELL TO SEPTIC TANK DRAIN FIELD WATER MAiN TO SEPTIC TANK DRAIN FIELD sEPT,° T^NK. TO RIVER, LANE. STREAM. ALSO CONSIDER AREA WELLS, DRAIN FIELD DIAGRAM OF SYSTEM CAST IRON INTO AND OUT OF SEPTIC TANK AND iNTO CRIB CROSSING GAP OF EXCAVATION S FEET INTO UNDISTURBED SOIL, 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIOHT REMOVABLE CAPS. GRA¥£1. BACKFILl. CONFORM TO BOROUGH REGU TIONS REGARDING INSTALLATION. I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DATE ' ?---- 7q-- A" L'C^NT'S S, NATU.E LA.,K~ ~950~ ~;1F~jc~~J. Mt. Park ~tate~ Foil The soil has some Sp and cobble bobles these account for ~ess than 5% of the total. TheMe is a moderate to high water content.- ~a~ ~and ~ater Encountered? No T~me Depth To' H2O Readln~q Date Gross e~co~ac~on , Net Drop Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 017-391 IZ a io at 1. GENERAL INFORMATION .4�IPeatS f0 �� a Complete legal description _MOUNTAIN PARK ESTAT BLK 7 LT 6 Location (site address) _5901 HOLDEN D Current Property owner(s) Joanna Lyons-Antley Day phone Mailing address _SAME Real Estate Agent 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone sD co5lq 'Fof bo -f-7 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual N Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: ,tel// / I -*,- Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $_ Waiver Fee $ Date of Payment 2/23/ l Date of Payment Receipt Number Receipt Number COSA # 69�-r _ I oca? Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE. Engineer's Printed Name MIKE N ANDERSON, PE Date 2/22/18 �,°oo•n e.a an: ao ncoo of c•o -�` 6. DSD SIGNATURE C 9/169bedrooms. w System #1 Approved for ° ' °� O ° ° #2A p, System Approved for bedrooms. �' L:..,1�����1` Disapproved. Conditional approval for bedrooms, with the following stipulations: -cy OFAk, WATER AND c WASTEWATER o - fin. _nom By: Original Certificate Date: �S The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet 10-10-12.doc If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system _ Certificate of On -Site Systems Approval Checklist Legal Description: MOUNTAIN PARK ESTATES BLK 7 LT 6 Parcel ID: 017-391-13 A. WELL DATA Well type Private If A, B, or C provide PWSID # Well Log (Y/N) Y Date completed 7.17.87 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 222 ft. Cased to 218 ft. Casing height (above ground) 24"+ FROM WELL LOG AT INSPECTION Date of test Static water level Well production WATER SAMPLE RESULTS: 7-17.87 170 ft. 5 912712017 ft. g.p.m. 4+ g.p.m. Coliform NEG colonies/100 mL Nitrate 0.989 mg/L Arsenic: ND ug/L Date of sample: 2-19-18 Collected by: Mike Anderson B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date installed 3.5-2018 & 7-7-87 Tank size 1000 & 500 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) NA Date of pumping 9-27-17 Pumper Around the Clock C. ABSORPTION FIELD DATA —1985 SYSTEM TESTED Date installed 7-7-87 Soil rating (sf/bedroom) 300 System type DEEP TRENCH Length 2 x 50 ft. Width 3 ft. Gravel below pipe 7.0 ft. Total depth 12 ft. Eff. absorption area 1400 ftz Monitoring tube Y Depression over field N Date of adequacy test 912712017 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 47 in. Water added 600+ gal. New depth 67 in. Elapsed Time: 1440 min. Final fluid depth 46 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) UNKNOWN If yes, give date D. LIFT STATION Date installed "Pump on" level at Datum Size in gallons Manhole/Access (Y/N) in. - "Pump off" level at in.High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main 100'+ Sewer /septic service line 50'+ Animal containment areas 100'+ SEPTIC/HOLDING TANK ON LOT TO: On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank 100'+ Manure/animal excrete storage areas 100'+ Building foundation 10'+ Property line 10'+ Absorption field 10' Water main 100'+ Water service line 50'+ Surface water 100'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10 Water main 100'+ Water Service line 50'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain 50'+ (None Known) Wells on adjacent lots 1001+ F. COMMENTS NEW 1000 GALLON TANK INSTALLED G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined through field inspections and review of Municipal records that the above systems are in� SR x 0 0 0 0 0 conformance with MOA COSA guidelines in effect on this date. O �• a a se.a s•aa s eevraoa •o ea o ° �' d a "''ca^Et Engineer's Printed Name MIKE N. ANDERSON. PE �' ° N. A Nn Esc;, , 0^�1• CE_ s469 Date 31812018 `t� a O] / �// ° •�;;\` ('�s `tib 9r ./,Pe.eed✓�"��n.� 'k,pil'�� COSA canary sheet_2-6-15.doc MUNICIPALITY OFANCHORAGE 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. # I~A'-}- o_)~1. ~ 1. GENERAL INFORMATION Complete legal description 7 5 Z, 1 Location (site address or directions) J Property owner Mailing address Lending agency Mailing address Day phone Day phone Agent Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 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. 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. 72-025 (Rev, 1/91) Front MOA ~21 5. STATEMENT OF INSPECTION BY ENGINEER DHHS SIGNATURE Approved for Disapproved. As certified by my seal affixed hereto and as of the validation date shown below, ~ 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 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofFirm ~'-~"~""~ ~ ~'~ Phone Address ¢'~ '~ I.~ lA-C~t ~=~ ~ Engineer's signature ~~ Date bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date The Municipality of Anchorage Depadment 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 th is 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. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: -//~ '~oe~.e,4,~ '-~.,~t ~.+ Parcel I.D. A. WELL DATA Well type ~ If A, B, or C, attach ADEC letter. ADEC water system humber ~r~/A- Log present (Y/N) Y Date completed "/37 / ~' 7 Driller '~t'l r~ v~ ,~- T°tal depth ~--~'~'3"~ .Cased to ~-'/g Casing height Sanitary seal (Y/N) / Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test 7//7/t7 Static Water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service' line MTJNICI~,ALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION 3 1 1992 RECEIVED ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout i~J/A Petroleum tank 'N WATER SAMPLE RESULTS: Coliform ~ Nitrate ~) I.~ ~ Date of sample: ~ ~1~ Z. Collected by: ,. Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed '7/'/7V ?/7/~'? ~Tanksize Cleanouts (Y/N) / Foundation cleanout (Y/N) Compartments / £ / Depression (WN) High water alarm (Y/N) Date of pumping Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: On adjacent lots Absorption field Well(s) on lot /aoO TO propertyline ~[ Surface water/drainage Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface ~t~r D. ABSORPTION FIELD DATA Date installed Length ~' ~ Width 3, Total absorption area J ~:~ Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating ~' ~ Gravel thickness '7 ! Cleanouts present (Y/N) Date of adequacy test for f'7 System type Total depth If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ 0 .c.~ On adjacent lots ~'/~-(.-~ Property line To building foundation I~' On adjacent lots ,5 Surface water ~'~ I [~ Curtain drain t~ J I~ To existing or abandoned system on lot Cutbank J'~'~ w ~- Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guideli~sin ef_,~_~,~,~ ~f this inspection. Date HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property Owner L~'l'llg.',/ ,~: _/~..~.~ Mailing Address Telephone: Home VO..¢.,O~.4."~' Business (C) Lending Institution ~.~0~1~ ~t~¢'~'~/ Mailing Address Telephone (d) Real Estate Company and Agent ~[~t.c,~f, J,~4.~'~'~ /~ J~,,4,¢..¢.¢.,.¢.~, Address (e) Mail the HAA to the followine address: or: Check here~ if hold for pick up. List contact person and day phone number below. Number of Bedrooms · WATER SUPPLY Individual Well/~ Community [] Public [] / Note: If comrTfunJty well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL OnsiteN Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. Page 1 of 2 72 025 tRey 8'861 Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the n umber 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 Jn compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm T~ Telephone Address / ~) _.~ J,~ /,-,"~ J~ Date Z~ C..- '/"'~ ~ Seal DHHS APPROVAL Approved for /~t'~,c~(~Z~).) bedrooms by Approved ~ Disapproved Terms of Conditional Approval Conditional CAUTION 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. Page 2 of 2 72-025 trey 8/86) Back A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARy 1984 264-4744 Well Classificatibn ' ~;~ If A, B, C, D.E.C. Appl'dved (Y/N) Well Log Present (Y/N) / Date Completed Yield Total Depth ,~._ Cased to ~ Depth of Grouting O Static Water Level ' /-'?~ Pump Set At Casing Height Above Ground ,.~./I Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) / Depression Around Wellhead (Y/N) Separation Distancbs from Well: To Septic/Holding Tank on Lot , 190' ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot _~ ~ O ; On Adjoining Lots To Nearest Public Sewer Line ~O~ ~, To Nearest Public Sewer Cleanout/Manhole J~ OJ~J ~ To Nearest Sewer Service Line on Lot Water Sample Collected by *~' '~. ; Date J '~'/ll Comments B. SEPTIC/HOLDING TANK DATA Date Installed '~ ?/'J/~' 8 7 Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Size 1o~o .1',-~o.0 No. of Compartments / '~ / Air-tight Caps (Y/N) ~'/ Foundation CleaDout.(Y/N) Date Last Pumped ~.~' I~/'A ;for Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ~ ~O TO Property Line ~ ~,~" To Water Main/Service Line _~ ~ Course /'~ O ~'~ ~----... To Building Foundation ~' ~ To Disposal Field ~ ~ To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026 (Rev 8/861 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~__ Width of Field Square Feet of Absorption Area ,il ~.~ Depression over Field (Y/N) ~ Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Welt /! ~ To Building Foundation ~.~ Lot O~'O TO Water Main/Service Line ~ J O To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Y To Properly Line S'~ To Existing or Abandoned System on ; On Adjoining Lots .~ ~ ~ TO Cutbank (if present) ~"~ O ~' Comments D. LIFT STATION ~ 0 ~1~ ~- Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified,Dr conformed to all ~ OA an d HAA guidelines in effect on the date of this inspection. Signed ~"~ ~.~'~/ Date / Company MOA No. ReceiptNo. c~O~)/ ~(")6") 0 ~ Dateof Payment /F)-- -~'/-) - ~ ~ Amount: $ // c~ 0 Page 2 of 2 Engineer's Seal  ENVIRONMENTAL ENGINEERING DIVISION FEB :l ~5 1980 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE~I~{clJ~i~r~E~ J~ MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~viR©b~ME~' i :'~LT;i & S25LStreet-Anchorage, Alaskag9501 , i,i, L , i2C'TION DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. PROPERTYOWNER~ Merrill Lynch Relocation Mgt. Inc. (Wilson) PROPERTY RESIDEN~.(If different from above} ~ Mr. & Mrs. Roland Wilson Not yet sold 2. BUYER MAILING ADDRESS PHONE 344-0980 PHONE 3, LENDING INSTITUTION N/A [ PHONE MAILING ADDRESS 4. REALTOR/AGENT Jack White Company .... Attn: Elliot Lawson MAILING ADDRESS 3201 C Street, Anchorage, AK 99503 PHONE 277-1553 E. LEGALOESCRIPTION 4 1 Lot 7, Block 7, Mt. Park Estates STREET LOCATION SRA Box 374-A ....... Holden Drive 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS ~, [] One [] Four [] Other SINGLE FAMILY [] Two [] Five MULTIPLE FAMILY ~ Three [] Six 7. WATER SUPPLY INDIVIDUAL* _~f[ ~[~t.. ~ * ATTACH WELL LOG. A well log is required for all wells drilled ~ COMMUNITY ~ ~.~t'~-- since June 1975. For weirs drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** I md~wdual/on-mte, give installation date . If system is over two (2) years old an adequacy test is required [] PUBLICUTrLITY by this Department. ~ ~' -- -[ ~, ~ NOTE: THE INSPECTION FEE M~T, ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, 72~)10(3/78) \ t THIS SIDE FOR OFFICIAL USE ONLY~ DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR I NSP ECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Uonnection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER ~31NDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line 1 WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS ~ APPROVED FOR -.~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev. 3/78) P Qu i ty ~' '/~/~l 3~'~C" Stree~ Anchorage, Alaska 99503 274-456l ~ Date Received ~h ~ Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Approval requested by: /~/q/ ~-~;~: ~?/~.., Mailing Address: .ailing Address: Legal Description: Phone: Phone: ?~'- ~./ ~ g 4. Location: Type of facility to be inspected Well Data: c. Co.str.ctio. 7. Sewage Disposal System: No. of bedrooms B. Depth D. Bacterial Analysis A. Ins~al]ed /~,,~,,-~/ B. Installer ~--",~,,~//~ D. Seepage Pit: 1. sorption Area ~_. 2. Material E. Disposal Field: Total length of lines Distances: A. Well to: Septic tank Nearest lot line /(~ B. Foundation to septic tank ~ C. Absorption area to nearest lot line /(~_~ , Absorption area , Other contamination , Absorption area , Sewer Lines EQ-034 (1/74) Page 1 of two pages GREATER ANCttORAGE AREA IBOROUGH_ Department of Environmental Quality 3330 "C" St., Anchorage, Alaska 99503 - 274-4561 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES 1. Type of Inspectio~.~ CMRO ~A _ FHA CONV 2. Property Owner: (~--~;~l'~.<~ ~, Mai-ling Address:~. -,.. '~,~TX/~ 17 ~/k"~, _ . Day Mai~ing Address: ~ . . _ Phone 5. Name. of Realtor or Agent: ~ ~,,~ Mailing .Address: Phone o 7. Type of Facility to be inspected: .~.~ No. Bdrms. .~ 8. Water ~upply Type of Supply: Public Utility Individual ~ If Individual, number of dwellings presently served If Individual, depth of well Sewage Disposal System Type of System: Public Utility Individual (on-site) If Individual, date of installation EQ-037 (]/74) ~a~e 2 of two pages - ReC Approval of Individual S~ Facilities Legal Description Comments Approved~ ~ ~ ,~t~-Disapproved Date Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ-034 (1/74) 1. Approval requested by: GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Mailing Address: Property Owner: REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR Date Received Time of Inspection Date of Inspection Mailing Address: 3. Legal Description: 4. Location: 5. Type of facility to be inspected 6. Well Data: A. Type _.r'/A/'x~--4x-~/'~-?x~/~lo. of bedrooms B. Depth C. Construction ~~___~ Sewage Disposal System~x~ A. Installed /x~?~ D. Bacterial Analysis / -77 B. Installer C. Septic Tank: 1. Size~~. 2. Manufacturer ~_~-~~__~ D. Seepage Pit: 1. Absorption Area ~.~J~. Material E. Disposal Field: Total length of lines 8, Distances: A. Well to: Nearest lot line /~ - , Other contamination B. Foundation to septic tank~j , Absorption area / C. Absorption area to nearest lot line Septic tank /d...~ x Absorption area ,/~,: × , ~, Sewer Lines EQ-034 (1/74) Page 1 of two pages · '"'*..Page. .2 of. two pages - R~¥ t fo~.Approval Of InUividual ~ , Ve~)al~escrl ptlon ~ ~ ~, Co" en s & Water Facilities Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM ---~' -~'-,~. : .-~ certify that the infor~mation contained in this request for.~a~p~ro~val to be a tr~e. and , accurate representation of the ~b~ect sewer and water facil~fet~rml~t~es~cilii~ie~ ~ Y~y are operating satisfactorily. SIGNED Date , , ,, EQ-034 (1/74)