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Home My WebLink AboutNORTH WOODS UNIT 3 BLK 12 LT 10 MUNICIPALITY OF ANCHORAGE · DEPARTMENT OF HEALTH & ENVIRONNiENTAL PROTEC'i'ION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME ) ' ~PNONE 0 Dwelling WeLl · . D'S~ANC~ TO: I ~[~1'~1 A~o~,~o. ~r.~ ""RM~T,O. ~ ~ Material ~.~ ~ ~ ~ ¢ N°. of compartments ' /~ ~bMEMADE: Inside length Width Liquid depth O ~ DISTANCE TO: Well Dwelling ~ PERMIT NO. O Z ~ Manufacturer ~ Material Liquid capacity in gallons ~o . ~ ~ I~n~h. of'~-~ Totallengthoflin~, Trenchw,~,:, Distancebetweenlines ~ , Top of tile to~h grade /~nches O - ~' 0 / Material beneath tile Total effective absorption area Length Width ~ inches ~ PERMIT NO. ~ Type of crib Crib diameter Crib depth Total effective absorption area m Well DISTANCE TO: Building foundation Nearest lot line ~ Class Depth Driller ~ Distance to lot line PERMIT NO. ~ DISTANCE TO: ~ Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS ~~ SOIL TEST RATING ~ ~ ~ ~NSTAL,~R ~O ..... MLi~-~ I C I PAL I T¥ OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET., ANCHORAGE, AK 9~50! 2~4-4720 'ERMIT NO: .ATE ISSUED: CIN--S,ITE 840]20 IPPLICANT. IDDRESS: ONTACT PHONE: EGAL DESCRIP: CT SIZE: OT LOCATION: AX BEDROOMS~ STEVEN L, SKAGGS CONSTRUCTION P 0 BOX ~70~0 CHUGIAK, AK ~9587 SUBDIVISION: NORTHWOODS #2 SECTION: ~ TOWNSHIP: 247~ <SQ. FT. OR ACRES> GREEN GARDEN DRIVE LOT: 10 ,RANGE: IW BLOCK: ISTED BEL01~ ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC ~STEM CHOOSE THE OPTION THAT BEST FITS YOUR SITE: BI=rD EPTH TO PIPE BOTTOM (FT.) 2.5 ~AVEL DEPTH (FT. > 0.5 ]TAL DEPTH (FT.> 2.0 ~AVEI WIDTH (FT.) 22.0 ~AVEL LENGTH <Ft.) 42.0 ~flVEL VOLUME (CU. YDS. ) ]4. 2 ~NK SIZE (GALS> i, 000. 0 )Il RATING <SQ. FT.~BR> 201 000. DEPTH TO PIPE BOTTOM < 2.5 FT, REQUIRES INSULATION DEPTH TO PIPE BOTTOM < 4.0 FT. MAY REQUIRE 8 LIFT STATION GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. TANK MUST HAVE AT LEAST TWO COMPARTMENTS CERTIFY THAT: i. I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALIT~ OF ANCHORAGE (MOA> 8ND THE.STATE OF ALASKA. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES RND REGUL~TIONS~ AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. 3. I WILL ADHERE TO ALL MOA 8ND STATE OF ALASKA REQUIREMENTS FOR THE' SET BACK DISTANCES FROM ANY E~ISTING WELL~ WASTEWATER DISPOSAL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR 8NY ADJACENT OR NEARBY LOT. 4. I UNDERSTAND THAT THIS PERMIT IS YALID FOR A MA~ID~M OF 3 BEDROOMS 8ND,~ ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, EN <l> 8N ELECTRICAL ~ERMIT AND INSPECTION MUST BE OBTAINED~ (2) AS-BUILTS LL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT.: A~ (3> THE ECTRICAL WORK MUST BE [~NE BY A LICENSED ELECTRICIAN, 3NED ~LICANT~ STEVEN"- '' '' "L SKiS CONSTraiN MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264~4720 SOILS LOG- PERCOLATION TEST [~ SOILS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3. 4 5 6 7 8 9 10 11 12 PERFORMED: $t!~'lt'~LL PocI'~E T5 SLOPE SITE PLAN 13. 14 15 16 17 18, 19- PERCOLATION RATE (minutes/inch) COMMENTS ,_.~'Oj/~..~ VI SC~ tg LL..~ I~.I~ TEI~ r~ETUJ~t~AJ / t ~/¢,. ~ i ' PERFORMED'BY: ~0~ .~.~< CERTIFIEDBY////~/~ ~ DATE: ~'~C~ 70 p~, ~,~Cc ~o~~ ~/~ - , MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904 On‐Site Water and Wastewater Section Fax: 343‐7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org Septic Tank Advisory Certificate of On‐Site Systems Approval # OSC201112 Subdivision: North Woods Unit 3 Block:12, Lot: 10 The septic tank for this property is 36 years old. The average life for a steel septic tank is 20 years. Typical replacement costs range from $6,000 to $9,000. This advisory must be attached to all copies of the subject Certificate of On‐Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 051-732-1'9 "~ GENERAL INFORMATION Complete~legal description HAA# Lot 10, Block 12, Northwoo~s S/D #3 Location (site address or directions) 23105 Green Garden Chugiak, AK P[operty owner Bob .... Mailing address · ' & Karen Leske 688-1057 Day phone Lending agency Mailiqg address.. Day phone Agent Prudential Vista/Barbara Crittenden 689-6464 Day phone, Addressl-6635 Centerfield Drive, Eagie River, AK ,99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 '~ 3. TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water XXX 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: XXX 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 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. Nameof Firm c,p.,SENGINEERING Phone ~c~-'~c7 7~ 17'034 Eagle River Loop Road No. 204 Address [:..~,,= p.~.,;,,,., Al~ska.~9_9577 / Engineer'S'Signature _~.//Z ~"7.v-',*---- Date ?//~ / ~ ~/ Sm DHH$ SIGNATURE b/'/ Approved for '"/'h//~E-E bedrooms. Disapproved. Conditional approval for bedrooms, with thee following stipulations: Additional comments By: 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-G25(Re~,1/91) Back MOA~21 Municipality of Anchorage ' _ DEPARTMENT OF HEALTH & HUMAN SERVICES~JUL 1 4 1999 Environmental Se~ices Division u_Y°F ANCHO~~ 825 L Street, Room 502. Anchorage,Alaska 99501* ?~~vlc~s Health Authority ApprOval Checklist Legal Description: ~7/~ ~/Z~ ~O~O0~ Parcel I.D.: O~/- ~Z--~ ~ A. WELL DATA Well type ~[ Log present (Y/N) IfA, B, or C, attach ADEC letter. ADEC water system number Date completed Total depth Sanitary seal (Y/N) Date of test Static water level Well production WATER SAMPLE RES.~ Coliform / Da.~m~mple: Cased to Casing he ght~ Wires ~o{ected (WN). FROM WELL [~OG ~~.~'~'1: INSPECTION g.p.m. Nitrate Collected by: Other bacteria g.p.m B. SEPTIC/HOLDING TANK DATA Date installed ~/////~z~- Tank size //~?~) ~ Number of Compartments Foundati?~ ~l~an~u~..~ ~5 Depression ~ ~ O High water alarm ~/N) Date ~mPih~'/~~ Pumper ~ / C. AB~0RPTION FIELD DAT~ ~'' ~, Date installed ~////~.~ ~: So ratina in n d/~= n~ ~ ~ Leng~ ~ : ~idt~, 'Gravel thickness below pipe . ~ Totaldepth Effectiv;'a tion area./_ M ni lng pr ) si o f / Fluid depth in absorption field before test (in.);~ Immediately after'gal, water added (in.): Fluid depth ~ // (ins) Minutes later: /~ Absorption rate = ~ ~ ~ g.p.d. Peroxide treatment (past 12 months) (Y/N) ~/~P[ ~ ~ If yes, give date 72-026 (Rev. 3/96)* LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons ....... ff. * " evel at .----- ../ *Datum _ E. SEPARATION DISTANCES Septic/holding tank on lot Absorption field on lot SEPARATION DISTANCES FROM WELLON LOT TO: ¥ Public sewer main .~ Public sewer manhole/cleanout S ewer/~i ce"'~'~ line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON' LOT TO: FOundation /.~/'~-- Property'line /O/~/' Absorption field J~-/~-/- Water main/service line ,,/0/7L Surface water/drainage /,~)O ~z Wells on adjacentlots /~///~' / SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line '/-/O Building foundation ]~ Water main/serv ce ne / ~)/~- Surface water /O~) /~- Driveway, parking/vehicle storage area /(~ /~- Curtain drain ,~/Q/V~ ~,~/'~ ~,',~./ Wells on adjacent lots ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of I in conformance with MOA H,~A ~li~ideline.~in effect on this date. ' Signature ~'~'~ ~ ~ ' Engineer's Name }~)~)-- i. ~ C~J~ are Date HAA Fee $ Date of Payment Receipt Number Waiver Fee $, Date of Payment Receipt. Number 72-026 (Rev. 3/961' ~. , ,~..-~, ,,~ .,- ~t ~g~J/ ~ E,AR~E~O[H~LTH &HUMANSERVICES -~-~,:;.' ~ :' ~'~:'*,. ,,~:,.;~,~.-,:~ ---- ,-; . un-~te ~e~lcesSectlon ~'~.~ '~.';;~: · '~ ~,,~'~ ........... . ~,...,~.- ~.~ :.:~-,~.~..~.,~- , ORI .:, ~rdirections) 23105 Green H~rn D~' USA FA Colo~o . ~ ' "~ Dayphone )n date shown below,' ! veri~,that 5. STATEMENT~ OF, INSPECTION.~ As certified by my investigation of this Health AuthOrity App~rova!apphcahon shows that the on-site water supply and/or wastewater d sposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my inves.ti_gation and inspection, the on-site water supply and/Or wastewater disp0saJ' syStem. is in"'c~r~plian~e"~ith all Municipal and State codes, ordinances, and regulations in effect on the'date. .. of this inspection. 17034 Eagle Riv~ LOOp Road No. :!04 :.:~ Address ~;. r,;,,,./, ~-,'. ~., ; ', Th=, &,~'*ni~n~li~ nf ~n~.'hnr~ 13e~artment Of' Healthand ,Human Serv~cas (DHHS)~asues Health. AuthoritY , ~,Approval ~ert ficates .based only upon the representations g!v.en~!n paragraph 5.above by an,,mdepe~dent ~ ~' ;:::~'~,'~n~,f~ ~a e~'"'~ ~eaistered n the state 0f AlaSka The DHHS does this.as a courtesy to purchasers of homes ~ :? ~nd t(l~'~lendi~nst~tut~ons m order to satisfy certain federal and state requirements. Employees of DHH$ do not Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744 Health Authority Approval Checklist A. WELL DATA ~: Well type _. - ~ Log present (Y/N) Total depth If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to Casing height (above ground) Collected by: Sanitary seal (Y/N) Wires properly FROM WELL LOG AT/It%SPECTION Date of test Static water level Well production WATER SAMPLE RES~TS.~~/ Coliform .. ./ Nitrate Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Tank size .~ O~ ~./.Number of Compartments ~' Cleanouts (Y/N). ~/ Foundation clean%ut (y/N) ~/ Depression (Y/N) Date ofp, hmpiag jc._/~ -~j-7,,, Pumper 67~,~' ) ABSORPTION FIELD DATA. Date installed 6Q//L~ ~2" Soil rating (g.p.d./ft2 or ft2/bdrm) 2no 2~,/'~ System type L ~'~ z ' eng~h ~ ~/,~ Width: 2,~'/' / Gravel thickness below pipe High water alarm (y/N) ~ Total depth -~ .'~'" Effecti~)~b~.sorptioa area ~ I :~-2 ~. Monitoring Tube present(y/N) Y Depression over field (Y/N) Date of adequacy test' Results (Pas,s/Fall) ./~,o_.~c ~' For bedrooms Fluid depth in absorption field before test (in.); ~ t9 ~¢ Immediately agter~ gal water added (in.):, Fluid depth /0 Minutes later: O ~/ ~ ~, ; i'~ (in.) Absorpt~onrate 'i:;' ~~7:~9 Peroxide treatment (past 12 months) (Y/N) ~// If yes, give date D. LIFT STATION Eo Date installed Size in gallons Manhole/Access (Y/N) "Pump on' lev~t at~~- "Pump off" level at* G High water alarm level at* ~ *Datum SEPARATION DISTANCES r'l"'l _., ~ o~ SEPARATION DISTANCES FROM WELL ON LOT TO: rt't'l ¢.,n c~ ~ Septic/holding tank on lot ; On adjacent lots ~ ~ ~ Absorption field on lot ; On adjacent lots i~.~~,~ n, Public sewer main ~t S~ §ervice line Lift station SEPARATION DISTANCES FROM SEPTIC~ TANK ON LOT TO: Foundation /O r ¢ Property line /t9 ','~ Absorption field Water main/service line /O '~ Surface water/drainage ,.'oo '/ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Surface water Curtain drain Water main/service line / ~ / Driveway, parking/vehicle storage area Wells on adjacent lots A////~ F. ENGINEER'S CERTIFICATION ! certify that I have determined thrufield inspections and review of Municipal reco.~~ Il?Ye systems in co~for,nance with MOA HAA ~uidelin~ in effect on this date. ,~'~-~.,?..~..~1 Signature ~ ~' ~ I~; "/ / J ~ ~- , Date ~ I It [ q ) ~' ~.~ CE ~801 __._ ................................................................... HAA Fee $ ~ · ~ W~ver Fee $ Receipt Number /?~ &~] Receipt Number are Rev. 8/95 OSS: haa.wk.doc 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description r.ot 10; Block 12; North Nood-~ Subd±v±sion ~'TT Location (site address or directions) 23105 Green Garden 249-1255 wk Property owner Ma?ng address benching aggn. CY Mailing address Agent Address Lee and Kathleen Fox Day phone 688-4812 Box 206 Green Garden, HC 80, Chugiak, Alas~2261~¢~¢ wk Day phone Day phone NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Unless otherwise requested, HAA will be held for pickup. NOTE: Public water If community well 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 i 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 inspectiom Name of Firm Address Engineer's signature 17034 Eagle River Loop Road NO; .HS SIGNATURE ~/~) Approved for /~/~-'-~- bedrooms. Phone Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ~_.__ ~ Date / 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 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ..~ lC) ~ 1.4z '/~ j-~o~-~ ¢0~)p~ParceI I.D. ~) ~'/ -- A. WELL DATA Well type /~ Log present (Y/NI Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level If A, B, or C, attach ADEC letter. Date completed Cased to FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ADEC water system number ~_~, % OC::, ~ Driller Casing height Wires properly protected (Y/N) g.p.m. AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate B. SEPTIC/HOLDING TANK DATA Date nstalled _ ~' -~ ~-~ '~ Cleanouts ~/N) ,,/ High water alarm (Y~[~) Collected by: Other bacteria Tank size ~ o o c::) (~,~'L.~ Compartments ~ Foundation cleanout~N) V Depression (Y~ Alarm tested (Y/N) Foundation Water main/serv ce line. Date of pumping ~ ~' Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot_ '7.--,=.¢ To property line, .t'~'~ Absorption field. Surface water/drainage 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at : ~ ; ~vel at High water alarm level J-'~'~-Cycles tested Meets MOA el.ectrical codes (Y/N) ~ VV~[I on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length ~ ~ Width 7---~f'~ Total absorption area Depression over field (Y~ Results ~fail) Peroxide treatment (past 12 months) (Y~) ~ 0 ~/~¢~-~ ' System type ~_.~C~ Gravel thickness Cleanouts present(~/N) Date of adequacy test for /~ {Z.~ ~/J. tf yes, give date Soil rating bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~-~ To building foundation On adjacent lots ~ ~ ~'~ Surface water Curtain drain On adjacent lots ~ IA-~ Property line To existing or abandoned system on lot Cutbank [~' Water main/service line Driveway, Parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. $ & $ ENGINEERING ; 7034 Eagle River Loop Road No. 204 Signature Engineer's Name Date HAA Fee $ Date of Payment .:~/~'~' / ~-- Receipt Number 72-026 (Rev. 3/91) Sack MOA 21 Waiver Fee: $ Date of Payment Receipt Number DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, ALASKA 99503 WALTER J, HICKEL, GOVERNOR (907) 349-7755 February 19, 1992 FOR: S & S Engineering PWSID # 213001 My review of the records on file in this office reveals that the Northwood Subdivision Class "A" Public Water System, is in compliance with the routine coliform bacteria sampling requirements listed in Table C, and with the inorganic sampling requirements listed in Table B of 18 AAC 80.200. Sincerely, Byron Roys Environmental Engineer BR/cf ~ ,- . x ,,~.~x MUNICIPALITY OF ANCHORAGE DEFF. OF HEALTH & M~CIP~I~ OF ~O~GE ENVIRONMEN'IAL PROTECTION D~SI~ OF ~~ ~ APPLI~TI~ ~R ~ ~O~ ~PRO~ C~IFI~TE 1. ~=al Infof~etion ~pli~tion ~kO~ ~ ~ [~ V ID (a) Legal Description (incl.u. de lot, block, SUbdivision, section, townshio, Lot/o. ocation (adck~ess or directions) d /] ixlq Dr(W, (b) Applicants Name (c) Applicant is (c~ o~) ~nding Insti~tion ~; ~r~il~r ~; range ) Telephone (d) Lending Institution Te le phone Address (e) R~al Estate Co. & Agent 'Address Te le phone 2. Type of l~sidenc~ Single-Family ~ Numbe= of Bedrooms 3. Water Supply Multi-Family~___l Othe~ (describe) IndividUal Well ~ Cu{~.,nity ~-~ Public ~ Note:. If cc~,,3unity wall system, must have w~itten confirmation frcra the State Department of El~viror,,rental Conservation attesting to the legality and status. Is the wall adequate fo~ the number of bedrooms specified in this'HAA (Y/~) y 4. Sewage Disposal Onsite ~ Publico Con~nunity ~ Holding Tank ~--~ Is the wastewater disposal system adequate fc~ the number of kedrocras (Y/N) V [Page 1 of 2] 2-15-84 5. En~ineerin~ Firm Providing Inspectionsr Tests, Data and Information I certify tJlat I have checked, verified, c~ conformmd to all MOA HAA Guidelines in effect on the date of this inspection. S igne( Nares of Firm Address I~/ gate '~"~ ,/~//~ ( ENGINEER SEAL) 6. DHEP Approval Approved for Approved ~ Disappro~d ~--~ Conditional ~-~ Terms of Conditional Approval The Municipality of Anchorage D~pa~tment of Health and Environmmntal Protection dces ~ not guarantee the continued satisfactory ~erformance of the water supply and/or the wastewater disposal system. This approval indicates that, as of the validation date shown abov~, based on the data and information furnished by an engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional fo~ the number of bedroans and type of structure indicated. (D~EP SEAL) 7. Mail the HAA to the following address.' KB2/d5/s [Page 2 of 2] 2-15-84 Well Classification ~]q]~l~ Well Log P~esent (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit ,(Y/N) Separation Distances'f =cra Well: To Septic/Holding Tank on Lot To Nearest Edge of Absomption Field on Lot To Nearest Public Sewe= Line Cleanout/Manhole Water Sample Collected By Water Sample Test 9esults C~u~nts MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 If A, B, c~ C, D.E.C. Approved~Y/N) Date C~leted Yield Depth of Grouting, Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; O~ Adjoining Lots ; On Adjoining Lots To Nearest Public Se~r To Nearest Sewe~ Service Line on Lot ; Date B..SEPTIC/HOLDING TANK DATA Date Installed 6<1-8 IOlYQ ll(rn% No. of Co, a nts Standpipes .(,Y/N) y Aid-tight ~ps (~) y F~n~tion Clean~t (Y~)~ ~ession o~ Ta~ .(,Y~) ~ ~te ~st ~d -- ~ ~/d_ P~ing~intenan~ ~n~a~ ~ File (Y~) ~/~ ; for - ~ Holding Ta~ High-Ware= ~a~ (Y~) -~ ~ra=y Holdi~ Tank ~t (,Y~) ~ ~p~at~on Distan~s ~ ~ptic~olding Ta~: To Water-Supply Well ZOO+ To Property Li~e ~]~ To Water Main/Service Line Course ~ " / TO Building Foundation ~1 To Disposal Field /Q, ~; To Stream, Pond, Lake, c~ Major D~ainage Counts [Page 1 of 2] 2-15-84 DEPT. OF ENVIRONMENTAL CONSERVATION SOUTHCENTRAL REGIONAL OFFICE 437 "E" STREET, SUITE 200 ANCHORAGE, ALASKA 99501 PWS i.D. # ~l~O01 BILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 To Whom It May Concern: ]cording to r~ecords on file In this office the .~i\/i~,lOt~.J Water System is in compliance with the State Drinking Water Regulations.