HomeMy WebLinkAboutTIMBERLUX #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)