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Home My WebLink AboutTIMBERLUX #1 BLK D LT 5Timb rlux Block b Lot 5 #018-271-17 1 Townsend, Curtis L. Subject:Legal Description: TIMBERLUX #1 BLK D LT 5 History of wells on this property Parcel Number: 01827117000 Legal Description: TIMBERLUX #1 BLK D LT 5 1981 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES was submitted to MOA DHHP reports that ‘well installed 1962’ 1981 inspection report shows only one well on property 1984 well log for a 47’ deep well 1990 as built shows two wells on property; one right next to the house and one along the western boundary line 1990 handwritten notes state that ‘original well drilled 1970 or before …..’ 1991 engineering drawings from Spurkland show two wells, similar to the 1990 survey as built. 1992 Alpine drilling cut casing 4’ below ground level and filled with concrete. Well was 210’ deep and SWL of 65’ 2004 as built from Walatka only shows the well on the western boundary 2004 Spurkland permit drawings only show one well on the western boundary 2025 survey from Johnson only shows well on western boundary. 1991 HAA Spurkland – DHHS comments that the “well adjacent to the house and not in use will require abandonment if not put to beneficial use in next 12 months”, Spurkland tests the 1984 well for flow and quality. 1992 HAA tests the 1984 well 1995 HAA tests the 1984 well 2004 HAA tests the 1984 well 2012 COSA tests the 1984 well MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP251075 Work Type: SepticTank Upgrade Tax Code Number: 01827117000 Site Legal Address: TIMBERLUX #1 BLK D LT 5 G:3136 Site Mailing Address: 15300 LONGBOW DR, Anchorage Owner: GALYON MINDY & MICHAEL Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 4/9/2025 4/9/2026 57586 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: ` �Date: Issued By: Date: r 3 ON -SITE SEPTIC/WELL PERMIT APPLICATION Parcell.D. 018-271-17 Property owner(s) MICHAEL & MINDY GAYLON C/O ARM SEPTIC SERVICES Day phone 907-688-9433 Mailing address 15300 LONGBOW DRIVE, ANCHORAGE, AK Site address 15300 LONGBOW DRIVE, ANCHORAGE, AK Legal description TIMBERLUX #1; BLOCK D, LOT 5 Number of Bedrooms 3 Engineering Firm GARNESS ENGINEERING GROUP Building Permit Number Not Applicable RE APPLICATION IS FOR: APPLICATION IS AN: (Z all that apply) Absorption Field D Initial D Septic Tank F Upgrade D Holding Tank El Renewal ❑ Privy El Well 0 THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: Permit/Rush Fees: Waiver Fees: Date of Payment: Date of Payment: Permit No. Waiver No. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251075, Curtis Townsend, 04/09/25 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251075, Curtis Townsend, 04/09/25 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251075, Curtis Townsend, 04/09/25 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP251075, Curtis Townsend, 04/09/25 4 0 .4 ' 3 2 . 4 ' 4 0 .4 ' 3 2 . 4 ' R E S I D E N C E S T O R YTHREE 1 2 'x 1 6 ' S H E D LEGEND UTILITY PEDESTAL DECK FENCE OVERHEAD UTILITIES POWER POLE EDGE OF ASPHALT RECORD DATA PER PLAT #66-152 SEPTIC PIPE WELL SEPTIC TANK LID TIMBERLINE SURVEYING AND MAPPING 17035 BARONOFF AVE EAGLE RIVER, AK 99577 907-242-5320 ryan@timberlinealaska.com FILE NO.: 25.048 SCALE: 1" = 30 FEET DATE: 3/25/2025 SHEET: 1 of 1 MOA GRID: SW3136 SCALE: 1" = 30 FEET(11"x17") 30'0' 60' AS-BUILT OF: ADDRESS: 15300 LONGBOW DR, ANCHORAGE, AK LOCATED IN: ANCHORAGE RECORDING DISTRICT LOT 5, BLOCK DTIMBERLUX SUBDIVISIONPLAT #66-152 Municipality of ~chorage :: "; Development Services Department Building Safety Division On-Site Water and Wastewater Program, 4700 S. Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Page of www. ci.anchorage.ak, us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/'OR WELL INSPECTION REPORT Permit Number: ..~/'O~O~:L. PID Number: ,en~: 3A."IEs, V&.-'~,~%";'~. 'Z-~' ~D~- WastewaterSystem: [] New [~Upgrade Address: ~ ~o~ ~ ABSORPTION FIELD lEVee LEGAL DESCRIPTION so,..,,.~: Well: ~ New ~ Upgrade ~"~ I~~ ~. ~ ~ ~. SEPARATION DISTANCES ~septic BHolding ~S.T.E.P. ~Other: ~ Septic Absorption Lift Holding Pub[i~dvate M~a~re: ~ Capacity: Tank Field Station Tank s~t Une w., ~ b O su,.¢, w,,.,7 0 ~'qo ~ LIFT STATION LOt Line I ~ ~ O Gal ""~'"~': BENCH MARK , . Eogineer's Stamp Inspections pedormed by: ~ Dates: 1st ,`1'* Development1 ~e~ces Depa~ment Approval Reviewed and approved by: r ~ Date: IB£NCH MA TOP NUII O£ HYORANT "J I 5 BLOCK D TIMBERLUX JAMES AND VICTORIA ZERBE 53000 LONGBOlq DRIVE I TOBBEN SPURKUNO e.~. I LOT 203 Iq 15TH. AVENUE AYCH. AK. 99501 (907,] 279-$915 PE£HIT # I SEPTIC SYSTEM AS BUILT DATE: NOV. 24, 2004 I SHEE~' 2/$ GRID: SI,TS I T~L 0~85£,BW6 PID # 018-271-17 ~ 3Z5 ~ T " NOI. ES AT $O" 5~ _1 -I NO SCALE 0.5 fl of Sep#c Effective 1.0 Fl' PiLE'~ Monitor / NB SCALE ITODBEN SPURKLAND P,E. 203 ~15~h Ave Anchorage Ak 99501 P79-fl~16 , 'PERVIT ~ SW040482 LOt '5 BLOCK D ?IMBERLUX JAI~ES AND VICTORIA ZERBE 53000 LOI~.,EOW SEPTIC SYSTEM SCHEMATIC DATE, NOK 24, 2004 SHEET~ 3'//,,~ ORIgl 3137 018-271-17 TSLOOO55.DWG MUNICIPALITY OF ANCHORAGE Development Services Department 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 Upgrade Date Issued: Nov 22, 2004 Expiration Date: Nov 22, 2005 Permit Number: SW049482 Legal Description: TIMBERLUX #1 BLK D LT 5 Design Engineer: 0007 Tobben Spurkland, PE Owner Name: JAMES AND VICTORIA ZERBE Owner Address: 15300 LONGBOW DR ANCHORAGE, AK 99516-4146 Parcel ID: 018-271-17 Site Address: 015300 LONGBOW DR Lot Size: 57586 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] 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 ( 18MC72 ) and Drinking Water Regulations ( 18MC80 ). 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 Date: 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 99519-6550 www.ci.anchorage.ak.us (997) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 01¢- ~--""J I- 1'1 Permit Number SW Property owner(s) Mailing address (1) Mailing address (2) Legal description (Lot, Block & Sub'd.) J-~ Legal description (Section, Township & Range) LotSize _~"7! .~"~(¢ Acres/Sq. Ft. Day phone Zip Code Number of Bedrooms ..~ THiS APPLICATION IS FOR: Sewer Only Sewer and Well Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub Swimming Pool Therapy Pool [] Well Only [] [] Water Storage [] [] Jacuzzi [] [] Water Softening Unit [] 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 owne~ or au~ Permit Fees: Date of Payment: Receipt Number: (Rev, 12/00) Waiver Fees: Date of Payment: Receipt Number: T SPrLPdG3AND PoE 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT $ BLOCK D TIMBERLUX #1 JAMES AND VICTORIA ZERBE Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street Anchorage, Alaska 99519-6650 November 15, 2004 We are 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 ofthe 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: Ground Water or at 10 ff Standard Bed Soil Rating. From Testhole 11-15-04 <5 rain/in = 0.8 galper sq. Pdday No. of Bedrooms 3 Required Area per Bedroom: 150/0.8 = 187.5 sq.ff. Total areamquired: 187.5 x 3 = 562.5 sql Minimum Trench Length 562.5/15 = 37.5 ff. SYSTEM CONFIGURATION STANDARD BED TOTAL LENGTH TOTAL WIDTH TOTAL DEPTH ROCK DEPTH FILTER SAND COVER SEPTIC TANK 37.5 FT 15 FT 3.5 FT 0.5 FT 1.0 FT MoA Filter Sand. 2% Passing # 100, 1% Passing #200 3 FT 1000 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. LDT 9 K F ~LDT 8 o III LOT 4 III K RA i~f 49~h R LDT 8 LDT VACANT TOBBEN SPURKL4NO P.E. 203 Ig 15TN. AVENUE ANCN. AK. 99501 (907) 279-3918 [LOT5BLOCKD TIMBERLUX JAMES AND VICTORIA ZEREE 55000 LONGEOIg DRIVE SEPTIC SYSTEM DESIGN DATE: NOK 12, 2004 SHEET: 1/3 GRIO: 3136 PERMIT # 2h/O4Oxxx Piti # 018-271-17 TBLOfl051,DI¥6 4RF~ No. CE-~2~5 -~ lfell I I 0 150 S~ALE; ,~' = 50 ET, //1 TOBBEN SPURKL4NO P.E. 203 If 15TN. AVENUE ANCX. AK. 99501 (~07,) 279-39~6 LOT 5 BLOCK ID TIMBERLUX JA~fES AND VICTORIA ZERBE 53000 LONGBOIf DR/YE SEPTIC, IYSTEId DESIGN SHEET.. 2/3 GRID: 313~ PERMIT #$t¢fl4Oxxx PID # fl18-£71-17 TBLODOS£.flV6 37,5 t 1-1t/4" PI~ fit. 3Ih" ~ ,41' .TO" 3;5' _1 -I NB SCALE 0.5 fl of Sept~ 2o~ £ffe,:#ve Monitor 1.0 Fi' fTLITR SAND NO SCALE ASSUYED EIt"V. lO0,O0 FT JTDBBEN SPURKLAND P.E. J J 203 ~/15th Ave Anchorage Ak 99501 P79-3916 PERMIT ~ S?/040XXX LOT 5 BLOCK D TIMBERLUX JAMES AND VICTORIA ZERSE 55000 LONGBOW D~IVE J SEPTIC SYSTEM SCHEMATIC DATE, NOK I~ 2004 SHEETI $//~ GRIDI 3137 TSLODO5$.D~G 018-271-17 Legel gescriplion: Municipality of Anchorage Development Services Depadmenl Building Safety Division On. Sile Waler and Weslewaler Program 4700 South Bragaw St, P.O. 8ox 196650 Anchorage, AK 99519-8650 v,,wvl,ci.anchoraqe,a k. u s (907) 343.-7904 Soils Log - Percolation Test ~,.~iL ~ j'~._ ~ Tl~,t'~l-~.v Township, Range, Section: Slope WAS GROUND WATER ...... -:=:, ~ Reeding Site Plan .I Deplh Jo Water I Ne~ Ore2 Tm_ST RUN ~ET~,A/~,~ Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~ff~'~lO~q~ PIDNumber: O1~,- ~..'~-- Name: ."~o[4~4.~evl. ~~ ~ Wastewater System: ~ New ~Upgrade Address: ~A~ LoNG ~ ABSORPTION FIELD . NO. of Bedrooms: Ph°ne:~O~, ~ ~l~[ ~ ~Deepmrench ~Shallowmrench ~Bed ~Mound ~Other LEGAL DESCRIPTION so,,,~,~: . ~ Total Depth fro~riginal grade: / LOt: Block: Subdivision: ~ ~ Depth to pipe Po,om from original grade: Gravel depth beneath pip~, T~h~ R~g~ ~I se~ Fill added above original__~grade:__ Ft. Gravel length: ~O Ft. Number of lines: [ Distance ~tween IJn~: WELL: D New D Upgrade Grave~: ~ /~ Ft. ~ ~ Et, Classification (Private, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material: Ft. Ft. ~ SQ. Ft. ~ Driller: Date Drilled: Static Water Level:Ft. Installer:~c~ Date installed:~ Yield: I Pump Set at: I Casing Height Above Ground: U GPM Ft. Ft. TANK SEPARATION DISTANCES ~ Septic D Holding ~ S.T.E.P. To ~ptic Absor~ion Ll~ Holding )ubll~PHvate Manufacturer: Capacity in gallo~s: Prom Tank Field Station Tank Sewer Lines Materiah Number of Compa~ments: Su~ace Water I~+ Im~ I~ LIFT STATION Lot [ Size in gallons: Manufacturer: Foundation ~ O J~O ~ "Pump on level ~at: JIi "Pump off~eve[ I ~ at:II High water 3 [ alarm at: Cu~ain PumpMake&Model [~le~tri~al Inspections pedormed by: Remarks: BENCH MARK L;~~, ~0 ~~ ~ LocationandDe~op O~ iption: '~ ~ I A~umed Elevation: I I ~ ~, . E~GI~'~EAL 'I -%. . nspections pe orme by: r D. ate : Departm.,t of H Hu ces app~ ',,. ~ Reviewed and appr Dat, . ~'- ~ _~.~ 72-013 (1/gl) MOA 25 100,00 104,4 6AL L \ i10,8/. \ rFT STA, TXI$ T, 75 10~ I ~ l SO 175 SCALE.. I' = 50 FT. 100,~ 15 X 40 CE-2225 ~ SPURKLAND P.E, 6751 W. D]MON9 BLVD. ANCH. AK, 99508-3904 LOT 5 J~LOCK D FIMJBERLUX ~ONALB T. JOHNSON 1~$~ LONG~O~ SEPTIC SYSTEM AS~UILT DATE, AU~ ~ 1991 SHEET, 1/2 GRI~,3J36 ¥ Monitor 0 CAPPALL ENDS 4O TEE INTO 2' LINE Monitor 2' PVC FROM LIFT STATION APPRD~ 330 L.£ 2' PVC i/8' HOLES AT 60' C-C 97.5 9ZO / Monltor /-- Monitor Ii2 3'Cover R// ~ M/raP/ I40 / ~ INSULATED UNDER II 97 6 in. o£ Septic Rock ~ AC PAVEMENT ELECTRIC~ ~ ~~ ~' ~CA~ ~D ~ i~300 Long-B~ /, 7-31-91 I5.00 1 po'~ar out.Iat PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW910196 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:JOHNSON DONALD T & GAY D OWNER ADDRESS:15300 LONGBOW DR ANCHORAGE, ALASKA 99516 PARCEL ID:01827117 LEGAL DESCRIPTION: TIMBERLUX #1 BLK D LT 5 LOT SIZE: 57586 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 7/16/91 EXPIRATION DATE: 7/16/92 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 (iSAACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: LOT S SEPTIC SYSTEM DESIGN BLOCK 1) TIMBERLUX DONALD T, ~ONNSON No Ground Water or Impervious Layer to Use Pressurized Bed Soil Rating. From test June 28 1991 4.2 mir~/in =.8 gat/mJ.n 10 ft. Required ~rea per- Bedroom: 150/.8 = 187.5 sq.ft.. Number' o,F Bedrooms Bed Ar'ma 562.50 sq. ft. SYSTEM CONFI6URATION BED TOTAL LENBTH 57.5 FT. TOTAL WIDTH 15 FT. TOTAL DEPTH 4 FT. ROOK DEPTH .5 FT. COVER 3.5 FT. SEPTIC TANK 1000 GAL. EXISTING 500 GAL. LIFT STATION ABANDON EXISTING TRENCH System Design 5 Block D Timberlox pg. 1 J u L - 8 1991 RECEIVED PRESSURE LOSS :,~;;.T,O Linear Feet of Main Line 3 lines at. 35 ft. each = 105 lf. 1/8" holes ~! 5 ft. = 11 holes Discharge per hele ~.~ 20' head = 0.852 gpm. Total, discharge: C).852 x 11= 9.4 gpm. Pump Rat:i. ng: 10 gpm ~. 135 .~t. Lees in Laterals: L,oss in Main: Plax Static Head: gpm Ignore gpm .J;45/100 ft' -5 ft. Total Head Lees = Loss at Orifices The installation e¥ this septic: system will not pr-event wells ~rom be inst. alled (:~n the adjacent lots. 'l'here ar'e no deve].oped or natural eur'~ace / sub surface drainage courses on th:i,s or the adjacent l~ts. The propoeed septic system will not change the general slope of the area. Pending and/or concentratien o~ surface runoff will not resuit Yrom this installation. pg.2 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: Township, Range, Section: 1 2 3 4 5- 6- 7- 8- 9- 10. 11 13- 14- 15- 16- 17 18 19 20 COMMENTS SLOPE ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth lo Water Afle~, j/ Monitoring? ~" '~ SITE PLAN I- N Reading Date Gross Net Depth to Net Time Time Water Drop 3~o ~ ~o ,~.~7~ ~..~ ~ ~o t~¢vY/7~ ~ q~ ~o 't ~o~ 'J7 5 'l5 PERCOLATION RATE ~'~- (minutes/inch) PERC HOLE DIAMETER ~-oo~ (..,. 4/85) [ ~)' L[/T 9 II LFJT 8 J LD[ 7 LO[. 8 Lg? LOT 9 N ~E L o c K ~,~V~L cREEK :TD]~3EN 3PURKL~Ng P,E, V, :?IMnN~ ]3LVD, AK, .L'[]~] L~,'~$~I~ SHEEn t5 X TDI~I~EN ~PURKLAN~I p,E, ~, DIMEIND AK, 99 50~-3904 L£T .ff £LDCK D T],N2E£LUX YEa" ,rN~] ~" LINE, 'T TD]H~EN SPURKLAND P,E, $751 W, DIH[]N]~ :~LVD, AK. 9950~-3904 · ~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGA DESCRIPTION LOCA ION ' ~ ~ Manufacturer ,~ ~ ~ Materi __ ~-~ No. of c~artments /~ f; IF HOMEMADE: ' ~ Well Dwelling PER~IT NO. O Z ~ Manufacturer Material LiquM capacity in gallons No. of linesI Leng~]~ach line Tot~r~t, of lines Tren~¢thinches Distance2~y lines ~ Top of tile to finish grad~ / MateHarbeneath tile ~ inches OTHER SOIL TEST RATING INSTALLER APP~ DATE CEGAL 72-013 er. 3/78) ~,.~EL_~ ..... F'ERMET NO. ,:: LEGRL ~ ~-~ ~ ~T'I~N~/D ~ L.OT~~~ SC4U~E FEET Piff,,<IMUM NUMBER OF EIEE:,RC~OMS = ........ THE LENGTH DIMENSION IS THE LENGTH ,::IN FEET) OF THE TRENCH OR DRR!NFiELD. THE DEPTH OF' R TRENCH OR PIT IS THE DISTF~NCE BETWEEN THE SURF.ACE OF THE GROUND RND THE BOTTOM OF THE EXCR;/RTION (IN FEET). THERE IS NO SET HIE)TH FOE'. TRENCHES. THE GRRk,'EL DEF'TH Ih3 THE MINIMtJH DEF'TH OF GRR',?EL BETWEEN THE OUTFRLL RIPE FtNE:, THE 80TTuM U~- THE E,:-:,CR',/RTION (IN FEET::,. ..,I?E~.~iJ I RE[) ~SEZPT I C: TR~,tI-::: '5 I ZEZ= ::L £~ E'-_.~ ~-7'~ PERM I T tBF F L I _-HNT HF~S THE RESF'ONS I B I L I T¥ TO t NFORM 'TH I S [:,EF'RRTMENT [:,UR i NG ]'HE INSTSLLRTION INSPECTIONS r~F FIN'-¢ WELLS R[:,JFICENT TO ]'HIS FR._.FE,.T~' RN[:, T .... NUME:ER OF RESIDENCES THRT THE WEL. L i,.!ILL SER'¢E. ']r-I!_..lC:~ ,:: 2 ) .IT I--.!_ ~_~.;F- E,£::T :[ C~l'ql~; RRE FJE~Z~iJ 8RCKFILLING OF RN9 Sg%TEM WITHOUT FiNRL INSPECTION RND RPPROVRL B9 THIS DEPRRTMENT P~ILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RN9 ON-SITE SEWRGE DISPOSRL SYSTEM ZE~C~ FEET FOR R PRZ'./RTE NELL OR :L5i8 TO 2E~C~ FEET FROM R PUBLIC WELL DEPENDING UPON THE TgPE OF PUBLIC WELL MINIMUM DISTRNCE FROM R PRIVRTE NELL TO,B PRIVBTE SEWER LINE I~ 25 FEET RND TO R COMMUNIT9 SEWER LINE IS 75 FEET. !4ELL LOGS RRE RE6¢UIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN OF THE NELL COMPLETION. OTHER RE6PJIREMENTS !dR'~' RPPL¥. SF'ECIFICRT!ONS RND CONSTRUCTION DIRGRRMS RRE RYRILRBLE TO INSURE PROPER INSTRLL. RTtON. E. F" E ~: ~1 I 'T ...... ~ -- '-- '9 '2" · ! _.E~%I. ~ THRT l: I ~M ,~RMILIBR WITH TH~'RE6PJIREMENTB FOR ON-SITE. ¢_,E[..ER_,'~I ": RN[:, !.,.IELLS RS SET FORTH. ~]:] THE MUM:[ E: I F'RL:t TM DF RNC:HORRGE '~: I ~L INST~LL THE S~S~EM'~ IN ~CC:OR[:,~NCE NITH THE~:ODES. 2: I.UNDERST~ND TNRT THE ON-SITE SEWER SYSTEM M8~¢ RE~LIIR. E ENLRRGEMENT IF TNE TO INC:LU[:,E Pi]RE THB},! ~: 8EE:,R. OO'r;~. [~ SOl LS LOG MUI~IIClPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION S2B L. Street, A~chorage, Alaska 99501 ;~64-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST PERPORMEOPOR: fili iq,::,-, fl. LEGAL DESCRIPTION: Tu~/~.l~-~. ! L,~-f.~' /~I~--~D SLOPE 1 3 4 5 6 7 8 9 DATE PERFORMED: /~ ~ i:~D ' ~/"~ SITE PLAN 10 11 12 13 14- 15- 16- 17- 18- 19- 20 E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Dace Time Time Water Drop PERCOLATIC ~ (minut~s/inchl TEST RUN BETWEEN ?, O FT AND ~ FT f Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-271-17 '1. GENERAL INFORMATION Complete legal description Location (site address) 15300 LongbowDdve Anchorage, AK99516 COSA# Expiration Date: Lot 5, Block D, Timbedux Subdivisio?l~~'. 1 Current Properly owner(s) Thomas and Cherri Vaughn Mailing address 15300 Longbow Drive Anchorage, AK 99516 Day phone Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. NUMBER OF BEDROOMS: Three (3) 3. TYPE OFWATERSUPPLY: 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 Approyal (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners, Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water 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 o As certified by my seal affixed hereto and as of the validation date shown below, 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 Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. Approved for ~ Disapproved. Conditional approval for bedrooms. Phone 522-7773 Date 8/1/2012 bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory (Rev 11/05} X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Cedificate Date: Z '~' / ~'~ '- / ~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www. munLorg/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 5, Block D, Timberlux Subdivision No. I A. WELL DATA Well type Private Date completed 7/13/84 Total depth 47 ff. Parcel ID: 018-271-17 IfA, B, or C provide PWSID Sanitary seal (Y/N) Y Cased to 47 FROM WELL LOG 7/13/84 Date of test Static water level Well production 15 WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Arsenic: N/D ug/I B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 1,250 gal. Foundation cleanout (Y/N) Y Date of pumping 11/21111 C. ABSORPTION FIELD DATA Date installed 11/22/04 Length. 37.5 ft. Total depth 3.5 ft. ft. g.pm. Nitrate .998 mg/L Date of sample: 7123/2012 Well Log (Y/N) Y wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 8/1/2012 43.1 [t, 7.5 g.p.m. Collected by: JKB Number of Compartments 2 __ Depression over tank (Y/N) N Pumper A Plus Home Services Date installed lO/81 Cleanouts (Y/N) Y High water alarm (Y/N) Y Y >18 Soil rating (g.p.d./ft2 or ff2/bdrm) .8 GPD/SF System type Shallow Bed Width 15 ft. Gravel below pipe .5 Eft. absorption area 563 ft2 Monitoring tube Y Depression over field N Date of adequacy test 8/1/2012 Results(Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in~ Water added 450 gal. New depth Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 450 Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date in. g.p.d. D. LIFT STATION Date installed 7/25/91 Size in gallons 500 "Pump on"levelat I7 in. "Pump off" level at 12 in. Datum Bottom of Manhole Cycles tested 3 E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot >100' Absorption field on lot >100' Public sewer main N/A Sewer/septic service line >25' Animal containment areas >50' Manhole/Access (Y/N) Y High water alarm level at 25 in. Meets alarm & circuit requirements? Y On adjacent lots >1oo' On adjacent lots >1oo' Public sewer manhole/cleanout N/A Holding tank N/A Manure/animal excrete storage areas >100' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Water main N/A Water service line >10' Wells on adjacent lots >100' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Absorption field >5' Surface water .~e~ ~,~oi ~ Water main >10' Driveway, parking/vehicle storage >25' Property line >10' Building foundation >10' Water Service line >10' Surface water >100' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS: ~. ~-='~- C,J A--I,J ~-tr~- o G. ENGINEER'S CERTIFICATION t 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 Michael E. Anderson, P.E. Date 8/1/2012 COSA Fee $ Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number 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,anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. Ol~- ~'~- I'"') 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Current Property owner(s) V ~ c.%'0¢4~, ~, .~,A;~M, I~-~ 'Z~PJ~CDay phone Mailing address 'i Lending agency Day phone Mailing address Real Estate Agent Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. NUMBER OF BEDROOMS: ~ 3, TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class .__ Public Water System Well 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 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 rs 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. NameofFirm '"'~J¢~..~¢rl/',--t~--~¢ ~/~-"~- Phone ~LTq-~,~l~, Address ~.o~:~ ~ I i~--~ ~OD Engineer's Printed Name ~~ ~h~v~ Date II1~0 lo~ I DSD SIGNATURE I./' Approved for ,..} bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: {Rev. 01/02) Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: /~- 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.anchorage, ek. us (907) 343-7904 Legal Description: A, WELL DATA . . Well type ~:.,, IfA, B, or C provide PWSID '-/~.~ I ~ ',{ (Y/N) Date completed , Sanitary seal Total depth LIT ft. Cased to ~"} ft. I FROM WELL LOG Dat,e. of. tes~t '"//il j~l.~ ,' Static water level ft. Well production /~) g.p.m. WATER SAMPLE RESULTS: Coliform ¢ colonies/100 mi. Nitrate I, ,¢... mg./L Arsenic: __~ mg./I. Date of sample: HEALTH AUTHORITY APPROVAL CHECKLIST b. SEPTIC/HOLDING TANK DATA Tank Type/Material ~ .¢:~-o, ~-~¢-, Tank size ~,~¢ gal. Number of Compartments__ Foundation cleanout (Y/N) y Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION · '~ ~ ft. b t/~ g.p.m. Other bacteria 1'4 ~ colonies/lO0 mi. Collected by: ~ 4 ¢14 ¢¢.~ Date installed ,2,.. Cleanouts (Y/N) Depression over tank (Y/N) N High water alarm (Y/N) Date of pumping 1% j ~.~ iV I.,~ Pumper [/~ &¢~_ ~ C. ABSORPTION FIELD DATA ~, ~__.~v/ Date installed ti'[%"Z- i¢'J. Soil rating (g.p.d./ft2 or ft%drm) i~. ~ Length 90 7. ~ ft. Width I ~' ft. Total depth % "~ ft. EFT. absorption area ,~ f,r.% ft2 Monitoring tube . Date of adequacy test 1'.4 [A- Results (Pass/Fail) '-'l'l'l'~ Fluid depth in absor,~.n field before test ~in. Water added ~g al. Elapsed Time: ~ min. Final fluid depth ~ Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) / System type ~) ..e- ¢/ Gravel below pipe ¥ Depression over field If yes, give date ft. For ~ bedrooms New depth ~ D. LiFT STATION Date installed "Pumpon" level at ]'7 in. Datum E. SEPARATION DISTANCES Size in gallons ¢¢~:2 "Pump off" level at },~--- in. Cycles tested ~2, Manhole/Access (Y/N) '"/ High water alarm level at ~.r~ in. Meets alarm & circuit requirements? '~/ SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 50 Property line Water main ,~O Water serv ce ne Wells on adjacent lots 1,0-- ~ SEPARATION DISTANCE FROI~'ABSORPTION FIELD ON LOT TO: Property line t",~ Building foundation Water Service line ! ~0 f Surface water /'~/O Curtain drain - fq }O Wells on adjacent }otc Absorption field J,'~ f.Y'~) '~" Surfs'ce water ~04¢, '~-~ Water main Driveway, parking/vehicle storage F. COMMENTS G. ENGINEER'S CERTIFICATION / certify that I'have determined through field inspections and review of Municipal records that the above systems are in , conformance w/th MQA HAA guidelines/n effect on fh/~ date. HAA Fee Date of Payment _ ieceipt'N~mber (Rev. 12101) Waiver F. ee $ Date of Payment Receipt Number ( Municipality of Anchorage P.O. Box 1~X;650 · Anctmragc, Alaska 99519-6650 *Tclcphonc (907) 845-8301 · Fmx (907) ~700 13ragaw Street , Anchorage, Alaska 99507 www.muni.org Mayor Mark Begich B~ S~e~ Di~sion December 9, 2004 Tobben Spurkland Tobben Spurldand 203 W 15th Ave, Suite 203 Anchorage, AK 99501 Subject: Waiver Request for Timberlux #1 Block D Lot 5 Waiver Request #WR 040093 Parcel ID # 018-271-17 HAA040642 Dear Tobben Spurkland: Your request for a waiver of the required 100 feet horizontal separation from the septic tank and lift station to surface water has been approved. The approved separation distance is 65.0 feet. This waiver approval applies to the existing septic tank and lift station to surface water separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, Civil Engineer On-Site Water & Wastewater Program Community, Security, Prosperity Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Waiver Review Worksheet WR#: 040093 PID#: 018-271-17 HA/Permig/ haa040642 Date Received: December 9, 2004 Legal Description: Timberlux #1 Block D Lot 5 Engineer: Tobben Spurkland Tobben Spurldand 203 W 15th Ave, Suite 203 Anchorage, AK 99501 Applicant: JAMES ZERBE Waiver Requested: 65' HORIZONTAL SEPARATION FROM SURFACE WATER TO TANK AND LIFT STATION Criteria: Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: Waiver is Granted: Waiver is not Granted: List Conditions or Reasons for above: Date: By: ~,U+ l l Name of'Reviewer Recg: 61539 Amount: $920 DatePaid: 12/9104 T.SPURKLAND P.E. 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 Municipality of Anchorage Development Services Deparlment On Site Water and Wastewater Program 4700 South Bragaw St. Anchorage, Alaska 99519 December 8, 2004 Subject: Waiver Request Lot 5, Block D Timberlux #1 PID 018-271-17 Gentlemen; We are applying for a waiver of the separation distance required between the septic tank, the lift station and "surface water". The "surface water" is standing in a ditch on the east side of Longbow Drive. When the septic tank and lift station were installed the ditch was relatively shallow and did not contain any water. Several years ago Longbow Drive was improved by deepening the road ditches and installing culverts under the driveways. TMs improvement resulted in surface water standing in the ditch. The lilt station is 65 feet distant from the ditch and the tank is 75 feet. The tank is a steel tank; it was exposed on November 24, 2004 and found structural sound. No corrosion or pinholes were observed. The lilt station is a HDPE tank, not subject to corrosion damage. Granting this waiver will in no way cause a potential threat to the environment. An overflow of either the tank or the lilt station will be diverted from the surface water by the ditch on the west side of tho road. The road it seffwill act as a barrier of both surface flow or subsurface flow if by some event either the septic tank or the lilt station become compromised. Yours MUNICIPALITY OFANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 9951g-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # . 0 t~- ~7/-- f? HAA # 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone Z Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ,-~ "~ 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. 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. the Municipali supply and/or, w~tewater disp~sa!: Ordinan~es, ~n-di~'g "'i ' ' ' Address :' ::,~:-., responsible for errors.or omission8 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501e (907) 343-4744 Health Authority Approval Checklist LeguiDescription: LoJc~ [~lX~'~ ~lV,,4[o.~v-~¢ Parcell. D.: A. WELL DATA Well type Log present (Y/N) Total depth Sanita~ seal (Y/N) Date of test Static water level Well production If A. B. or C. attach ADEC letter. ADEC water system number Date completed 7/~/~ 5/ Cased to LT/7 Casing height (above ground) y Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION ¢ 7 WATER SAMPLE RESULTS: Coliform ~ Date of sample: ~/i;L ~//~ ~~''- Nitrate B. SEPTIC/HOLDING TANK DATA Date installed I O/~> [ Tank size I~)- ~ ~ Number of Corfipartments __ Foundation cleanout (Y/N) 7/ Depression (Y/N) ~ DateofPumping 7/Y--2-/*~ Pumper A 76 C. ABSORPTION FIELD DATA Date installed Length L/0 Width Effective absorption area ~v O~ Date of adeqnacy test C,?//~ ~.~/ Soilrating (g.p.d./fl2orft2/bdnn) o ~> System.type '~-J /,~ Gravel thickness below pipe t/p Total depth /'r/ / Monitoring Tube present(Y/N) Y Depression over field (Y/N) Ix/ Results (Pass/Fail) ~p.Za For ~ bedrooms Fluid depth in absorption field before test (in.); ¢, It Immediately after ~Tgal. water added (lo.): Fhfid depth ~ I~ (ins.)i',l~nu:.ca later: ff--¢J/~,, CE, Absorption rate = 7t9'~ g.p.d Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date 1"'//,~ D. LIFt STATION Date installed Manhole/Access (Y,qN) y High water alarm level at* Cycles tested ~ E. SEPARATION DISTANCES Size in gallons ~Pump on" level at* / 7 *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line "Pump off' level at* /,,~ : On adjacent lots : On adjacent lots Public sewer manhole/cleanout Lift stat/on 17~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~:v ~) Properly line I 2~) Absorption field '~ Water main/service line 7,~ ~' Surface water/drainage N ] D Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Surface water Curtain drain ~ HAA Fee S ~' ~ Water main/service line Driveway. parking/vehicle storage area Wells on adjacent lots Property. line ~) ENGINEER'S CERTIFICATION I cer#fv that 1 have determined thru field inspections and review ofMunict~airec~._~P~ t~¢'~b'oV~ ~v'st~ins are - ' - ~'?d , ~ '~ ~ · - n co *formance ;, th MOA I4MA gmdehnes in e ect on this date Date ~ 4. ~ 179~ Waiver Fee $ Date of Payment Fr)/.~'~-/r~.5' ~ Receipt Number ~/.~, ,,~ '2) d~3q7 .) Rev. 8/95 OSS: baa.wk.doc Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE 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.# O/~- 6,~-~ ~'l'~ HAA # ¢./~ ~3.['~.'z'~ ~-~'') 1. GENERAL INFORMATION Complete legal description Location (site address or directions) t :~,~¢-~ ~,- o 1~6'~ o '¢~/ Property owner Mailing address Lending agency Mailing address Day phone Day phone Agent '7~..¢~1t~__ ,q ll~.,,~ g-I Address Il:Lo Unless otherwise requested, HAA will be held for pickup. Day phone NUMBER OF BEDROOMS: ~ ',, 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. 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 1/911 Front MOA #21 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 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 -~ ~2b.~_.~1 ~)Fv,c-~/',~L¢~ pL~.~- Phone Address ~ ~ ~ 1~ . . ~/~~ Engineer's signature ~ ~. Date DHHS SIGNATURE ~ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ...~ H-~ ;~lqA ! ~-q-~, Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Cedificates 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. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type ~ Log present (Y/N) y Total depth /'~ 7 Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~/~/~/,~/-;'/ Driller Cased to ///'7 Casing height 7 Wires properly protected (Y/N) / FROM WELL LOG Date of test -I/I//~' ~ Static water level Well flow I ~' g.p.m. Pump level '~ "~ AT INSPECTION SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~) Nitrate Date of sample: ~D/ ~' ~ [~ Other bacteria Collected by: '~- '-0'O'O~ B. SEPTIC/HOLDING TANK DATA Date installed I°/~r 1 Cleanouts (Y/N) ~'- High water alarm (Y/N) Date of pumping Tank size ! ~3--5D Compartments ~- Foundation cleanout (Y/N) '~/ Depression (Y/N) ~/'~'~' Alarm tested (Y/N) t'/,///~ O~'/¢7//'/'~'- Pumper Jl'~t-"~'x SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot J ~ To property line Surface water/drainage Onadjacentlots ,~ I¢"~'~ Foundation -~'7 Absorption field ~ '~ Water main/service line (e.-~ 72 026 {Rev. 7/91) From CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) ~ High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer ~ ¢. ~'¢--~--~P~ Manhole/Access (Y/N) / '~ "Pump off" level at Cycles tested 12- SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot J '7'D On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed "7'/~'~'/~ I Length Z./~) Width Total absorption area Depression over field (Y/N) ~ Results (pass/fail) ~ Peroxide treatment (past 12 months) (Y/N) Soil rating - Gravel thickness System type ~,,.~ ~ I Total depth Cleanouts present (Y/N) Date of adequacy test for /7/I bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I ,~O To building foundation On adjacent lots .'> Surface water t'~ Curtain drain L"'L On adjacent lots .~ /f-.~'¢~ Propertyline ~.-'-'-'~ To existing or abandoned system on lot ~.&~.~ -Jr Cutbank t'~,,,...l~ Watermain/serviceline ')' I--~' (~ Driveway, parking/vehicle storage area ~ ~ 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. HAAFee$ /~ Date of Payment Receipt Number 72~26 (Rev. 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number 31 A 11]"D' 31 MUNICIPALITY OF ANCHORAGE 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. # 1, GENERAL INFORMATION Complete legal description Location site address or directions) __~_5 ~o--~::~ L- o rig Property owner Mailing address Lending agency Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well NOTE: _Day phone Community well Public water If community welt system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer 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 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 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. NameofF rm Address ~,O % ¢~ /,-~ ~ Engineer's signature "~~ Approved for Disapproved. Conditional approval for Phone DHHS SIGNATURE bedrooms. bedrooms, with the following stipulations: By: Additional Comments 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. 72-025 (Rev. 1/91) Back MOA #21 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~')\~-'-~--~/- ',-'~ HAA# 1. 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 Mailing Address Telephone: (home) Business (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address (e) Telephone Mail the HAA to the following address: (or check here.',',',',',',',',',l~, if hold for pick up.) List contact person and day phone number below: ! 2. TYPE OF RESIDENCE Single-Family/~' Number of bedrooms 3. WATER SUPPLY Well'¢!~ Community [] Public [] Individual Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ~' Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88} Page 1 of 2 5. 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, functiona 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 '~/~J¢-4~1. ~J~.¢'~ '~.l~ Telephone Address ~7,.~/ LJC/, -~)l t4i Ol'vZl~ ,/~. ~ l.~¢,. .,~ ~' 6, DHHS APPROVAL Approved for ~-~ Approved Terms of Conditional Approval bedrooms by ..~ o L--~ ~C-~'~. [ ?"Ty-- Date Disapproved Conditional ~ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements, Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The M un ici pality of Ancho rage is not responsi hie for errors or om issions in the professional engineer's work, 72-025 IRev 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) ~ Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: J. eT ~'~ r'~ "~"ii4.'B~r~ LL~,~ Well Classification Well Log Present (Y/N) ~ Total Depth~Cased to Static Water Level Date Completed ~///'~/~, 17'/ ~"'~ Depth of Grouting ~' ~'~ Y Pump Set At If A, B, C, D.E.C. Approved (Y/N) Yield /~ ~ ~ ~..~. Casing Height Above Ground /~/ ''~ Electrical Wiring in Conduit (Y/N) ~'~ SEPARATION DISTANCES FROM WELL: To Septic/~c!dL-..g Tank on Lot I ~"C) ~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by ~.~' Water Sample Test Results Comments K' U~ ~ Sanitary Seal on Casing (Y/N) V Depression Around Wellhead (Y/N) ; On Adjoining Lots IO¢ '~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date .l ~ ' ,( .;. :, B. SEPTIC/HOLDING TANKDATA ../ Date Installed lul4l "~Size 1~50 No. of Compartments Standpipes (Y/N) ~, Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/~ TANK: ; for Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course To Building Foundation To Disposal Field Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Type of System Design 7~,~/~ Square Feet of Absortion Area / ~ ~, . Depression over Field (Y/N) /~ f Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test Results of Last Adequacy Test ~r ~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well /~3 '/' To Building Foundation ~, ~, ~ Lot Yv/,~' To Property Line /~ ~- To Existing or Abandoned System on ;On Adjoining Lots ~ ~C~ To Water Main/Service Line ) j'"o To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutback (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at / High Water Alarm Level at / / Tested for / Meets MOA Electrical Cod/eS/(Y/N) Comments Dimensions Manhole/Access (Y/N) / "Pump Off" Level at Vent (Y/N) / Pump~ Cycles during Adequacy Test. / **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA~uide[ine~ in effect on the date of this inspection. Signed Date ~ ~ ...~¢~ ,. ...... ,~. :/~ Engineer's Seal MOA NO. Receipt No. 7~%*~.':~-¢~/ , ;.. Waiver Fee: $ Receipt No. Date of Payment //~ / -- Amount: $ Date of Payment 72-026 (Rev. 7/88) Bsck Page 2 of 2 675! W. DI~ON~ BLVd. ANCHORASE~ ALASKA 79502-5904 (907) 248-5095 City i~ler't gag e 405 W .~,6tl Ave. Ar'~clhor'a(:;e Alaeka 995 () 5 J oh ri s orl / J or d a~] Lot 5~ Block D~ 'Timberlux Mur~licil:)a]L Health Ce~ ~,.~ _ate Dear Ms. Gusset'.t; December 3~ 1990 MUNICIPALITY OF ANCl4OI~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIOf*J 719 RECEIVED ~/Jy c:cm~pany was hired by Mr. Jor'clar~ to perform the requ:[red Flealt:l'~ Au'El-lol"'it:y Inspection and Testir~g er'l tlJe well and sept:Lc system cmn Lc)t: 5 ~ E41 o(::: k g ~ ]'i fnber t L.L>( . Thi s ~;Las~; clef]E? on t he 2.~;rcI o~: 1990. The inepec:tierl and t. es'L:s indicated that both N"~e well and sept;i c eyetem had el..J{ ~ i (::ii e,n'f: I:apL~c: i t i es to serve a ~:hree bedroc)m During the review c:)~ my worl.::~ the Munic:ipal Fteatth Oepartment requeeted that additiaeal (;estirlg and monitering be I:)er~or'med :i.n · ~eet eT the bc~ttom e~ the septic syetem. The Munic:ipal Cede I~igh groundwa't:er table and the lc)west point o~: the c:lr"a:i.l'~:i.e:t.d. [~r'OLtr/d water levels can ~lt.uztuate with the seasorl, and the fact that grourJdwater ie not present at one time o.F the year' does not On November 15 two c~beer'vati or]s wel 1 s were i r~st'.at 1 ecl i i"~ the vicirlity (:).~ the drainfield. 'f'hese wells wer'e inetalled tea del:~th apprc)xima~mZIy fc:)Ltr ~eE~,t below the bet. tom of the ~:ield~ and placed an eqeal dJ. eLar~c:e fr'om each er'id o'F the field. The 'Field is re- c:orded to be ):[4 ~eet lor~g and 8 fee'L: deep. These two observation wells have been illepected regularly. One well was clry and t:he other showed 12" o.F water on November 17. Durirlg {the next two weeks the 'First well remained dr"y~ ~;hi].e the If the water- obeer"ved ir'l the one well is indeed greurldwater'~ the drair~¥ielcl is in vielat. J. en c:)T the Mun:i. cipal Code anct mLtst be r'ep 1 ac:ed . ]-h6.D c:]bser red water ma'y ~ however eysta, m it:sel{; ffi(i)l'litteriFic] the well over' time (zar'~ i~dical.:e the er:i.g:Ln o'(: this water. the wat:er 2 evel i n LI c. weli stabJ 1 :i. z et-:i at a certai i] Ievel , al',cl t:his :l(-':~x,'e:L c:err'E'el;c~ride to 't:he Z~qu:Ld level ~n the dr'azr~:i, eZd~ Johnson/Jer'dar'i Health December E;, 1990 pg. 2 Authorit. y ~::hen the observed water' can be attribL~ted to tl"le eeptic system and the system will be judged Eo be in compliance with the Code. I~:~ however' ~ the water level ~1 uctuates with pr'ec:i pi '~:ati c~n ~ snowmelt and spring breakup,, then the water is ground ~,~ater and the system will be in violation o~: the Code. A cle'~:e~mir~at:ior~ this regard can net be r"eacl'~ed until May or ,June next year. ]he Health Depar'tment have agreed to issue a Coriclitionai Apprclv .... al , i¥ '~unds c'an be sec::ured ta cover the c:~st o¥ replacing th~ ~:ield, i.~ this becomes necessary. 'These Yunds are not: to be released until the Health Depart. merit is satis.~ied that a con~or'm lng system is serving this lot~ and an unconditional approval has been issued. When Yunds are t.o be put. in escrow to cover the cost. o~: install lng replacement systems~ it has been the corr~mon prat:rice to obtain two or t. hree ~ir"m bids. These bids are usually based an Municipal approvmd design; a design that is based on actual soil parameters ancl so:il c:o~ditions, the highest ground water level being one o~ ~hem. ']'hes(e replacements have be~en req~.Lired ar]ce w:i. th the regL.L].L~tiOI]S. In the case o~ Jehr'isen/Jordan~ J.t is suspecf:ed t. ha'E ~he system may ne[: be in compliance and it is only possible that the system mine i'F this is so~ and also the con~iguratiel'i o~: the rep].acement determ:i.r~ed until, the ground water level is known~ again iLate May the groul'Jdwater' level is 10 ~eet or higher, a pressurized bedsys- Eogether wil:h a li~t station and a bed ~n the general area o~ the preeent system. Using a marg:Lnal sell percolatior~ rate o¥ 60 mir'~, per inc:h , a 1500 s.~. bed wi].l be needed. I '~:eel that a li~: sta'l:.ion and a bed o'~: this s:i. ze can be inet. ailed ~of :¢7000 or less. Usirlg Ehe common practice o.~ es(::rowing 150% oE the est:[mat- ][ hope my analys:i.s will enable you to arr3. ve at a suitable escrow 'Figure. F'lease let me know i~ Eur"thcar c:lar:i.~ic:atien wilt be 6751 W, ~iMOND BLVD. ANCHORAGE, ALASK~ 99502-5904 (907) 2~8-5095 RESIDENTIAL WELL INSPEDTiON LEGAL: L.OCATiON: OWNER: TYPE OF WELL: WELL LOG AVAILABLE: iNSTALLATION REQUIREMENTS MET: WELL YIELD FROM WELL LOG: i,o'L 57 Blc)(=k D, ¥imber iux SiD ~:'I" ii ' ...... PUMP YIELD FROM TEST: 6.5 ba].].or~s per Minu'~e DATE OF iNSPECTiON: October 23 :i970 TEST PROCEDURE: Wm, l:l. was ?umped a'L a ~:::(::~l'~i~,'i::at"~'t':. rate (::).F 6.5 [:)~ pump:i.n(.;~ th(,:) wal:.¢=~,r ].ev¢] st. al::):i.I:i, zed a'i:: 42 ¥ec,'¥:. Dur:[ng the r~exL:: 45 minutes the w:::rEer level did not cl'iarige,, A total 500 o-¢ TEST FOR E. COLi AND TOTAL NITROGEN: War;er was¢ 'LEs'Led 'For E:, Coi:i ,':~'"~ cl .i: (:)'(~ a ii. ~'i i 4,: i'" (]¥;4 (.:~rl (mt Iii:. Col :;'. O. 'f'o't:a! N:i. i:~r cx?~:.~,n 0.2.3 mc)/].. Plax ,, a,i .t. (:::,~,h:_,d::~ .!. ,:c.~ 'iota,( N:i. ti-'c, gen ). 0 mg/ l . TEST RESULTS: 'i"h:i. s we]. I meets the r'equi r'emer'.,ts o'f 1=he i'iun i c :i, i::) a :l, i 'i:' y (::,.',.: ¢::~ ~ (:: h (::u' ag ~. THIS WELL WILL PRODUCE MORE THRN 3 GALLONS PER MINUTE FOR MORE THAN FOUR HOURS l::x~:~r bedr(:;)on-~ per" d~ty. 'I'iJis well exceed this r"equir'~:.z, mer~t. 'J'he aqui'~:er '~:~:~.::~d:i.n,:.4 the) ~,~:(:,:i. t . ea m > > 0 Cf) I cr, M > m z 33 M m 7z Z -1 0 Co 0 �i z 0 n 0 M o z m * --4 0 Z:z 0 M m 0 m --i 00— z _u m 0 ,4 7 3 5 cp o i 2, < 5-7,0 (D CD D X CZ 0 CD :3 *. !R 0) 0 w C7 m o A N So to. cD 3 CL CD F -a cn 0 'D " 6 CL U) w > :3 C- 5 m -nl< -0 CD :3 :0 CD R 0 i3 0- 0 :5 0 w c :3 CD =L 0 m 0 0 5 CD 3 (D P CD 5-0 CD CD CL < z- CD a - -0 to CD (D co 3 ID2D fn C- L/7—// /7—Y yvt Si I ] ~( ,ir, i :: 9El g~'~: ¢: ? F-:EHI:4::,, F'F, OPERTIES; F'. 2 ~NYII~ONMENTAL NOV ~ o O 1990 RE( EIVED i907) 24B-50~5 S__E_F_?_I~ _SYGTE_~. A__D_E_Q~_A_C~Y_ T__E_S'~ LEGAL: LOCATION: OWNER: RESIDENCE: WELL: SEPTIC SYSTEM: DATE OF LAST PUMPING: DATE OF TEST: TEST PROCEDURE: Sy?L~:,i~',, w~:~.:~; :ins!:::,~.?c:b:~d and ¢~easu. r'~:.:,d. 'l'anl:: :¢.ru:::ii¢~i;,, "ir~:eru::;l'~ ff~C)FiJ.!';E:)F '?U}:)(:2 NEE~ ? '",-E,E?I: (df}::'E,p b,¢ l~. 'l:'. f", 23.~.:J ;l i qU:i d. TESI RESULT: ';.7.1167 ch r ; I:),~]. i i' v (:l-f Anchor,T:iq(.~. "INSPECTION APPOINTMENTS 5. LEGAL DESCRIPTION STR3;ET LOCATION 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS 9?'- SINGLE FAMILY F-1 One E-1 Four r-71 Other ED Two 17-71 Five 7. WATER SUPPLY 1�9-'INDIVI DUAL* ATTACH WELL LOG. A well log is required for all wells drilled ED COMMUNITY since June 1975. For wells drilled prior to that date, give well ED PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM 1�5' INDIVIDUAL/ON-SITE-- YEAR ON -SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. '~..~`.~.='"' THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ TWO ❑ FOUR ❑ SIX ❑ OTHER 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED o INSTALLER ❑Septic Tank or ❑ Holding Tank Size: f If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL t r 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY ` 72-010 (Rev. 6/79)