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HomeMy WebLinkAboutT12N R3W SEC 15 LT 134 MUNICIPALITY OF ANCHORAGE DEPARTMENT O1" HEALTH AND HUMAN SERVICES Environmental Health Dlvlskm ~ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPOFIT ~m. I t , DISTANCES /~ J'- L-C --~-- TO SEPTIC ABSORPTION WELL Addross FROM ~..~ TA_NK FIELD Pho,~(~) P~,m~ No No o~ 8.d,oom~ WELL / TANKS ~ SEPTIC 1~ HOLDING ~TRENCN ~ BED ~ W. DRAIN ~OTHEFI i Depth tO pipe bottom Irom~ Total depth Irom original grade ~C)O S~ FT ~) FI' -- ~ PRIVATE ~ OTHER fldentifv~ REMARKS: S&SENGINEi~?If4G cedily that Ihis inspeolion was p,dormed according to all 72-013 (3/85) --I A5 BUILT [::ul'l!:d,!, (3N }::,/ :!,) / / Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION 'I'ES'I' PERFORMED FOR: LEGAL D E SC R I PTIO N: 2.~,1 ~__..~ 1 2 3 4 7 8 9 10 13 14 17- 18- 20- DATE SLOPE SITE I'LAN ~ WAS GROUND WATER ENCOUNTERED? S YES, AT WHAT OL DEPTN? - p E (]splh lo Water ~:~?. MonitorinD? _V' P'~'~ Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (m~utes/~nchj PERC HOLE DIAMETER TEST RUN BETWEEN FT AND __ _FT Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOI..ATION 'rEST 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19- 20- DATE Township, Range, SectJon:"'~-'~ ~_f,~ SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WRAT DEPTH? Depth [o Water Monitoring? 5~-~ SiTE t~LAN I Gross Net Depth to Net Reading Date Time Time Water Drop _ . ~ {~ 7 PERCOLA'rlON RATE /J~~ __ {rnmutes/~nch) PERC HOLE DIAMETER TESFRUNBETWEEN.~--FTAND 1 --FT COMMENTS ~1~1~ -/~// / / 4 Ea le R~ver Lo p Dad No 204 / ACOORDANOEWI'rHALLS,AqEANDMUNIOIPALGUIDE~FECTONTHISDATE. DATE: // ~'7 '" ~ ~-~ MUNICIPALITY OF ANCHORAGE ~'~O'"~/~1~ ~\/"~- \\DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION (~ ENVIRONMENTAL ENGINEERING DIVISION 825 L. Street - A~chorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~AME ~~' ~ ' ~ rPHONE MAILING ADDRESS . DISTANOE TO' J ~ ( [ ~ ' ¢ ~ ~~__ No. of compp~ntments ~ DISTANCE TO: Well Foundation Nearest lot 'ne PERMIT NO~ ~ T' , ,, ' -- ~,~- ~nches Total effec~Oon area ~ opoftieto ,nis,grade ~ ¢ Material bet~oath tile _____ ~ inches OTHER ...... ' PIPE MATERI ~ SOIL TEST RATING /(7~ Li~ ~, ~,. ~ ', .....,,~ __ ~p~O~ED ~ ' DATE LEGAL .... _. 72-013 (Rev. 3/78) F'ERH I ]' NO. RF'F'LICRNT DOUGLFIS GI:ILLf~NT LOCR"FION DE HFfRT RD. LEGRI_ LT 7~34 4:L2 POTTER TYPE OF SOIl_. FtBSORPTION SYSTEM IS: TRENCH RD. LO'F SIZE 272-'2201 h'IRXIMIJM NUHBER OF BEI)ROOhlS = 4 SOIL RBTING (SQ FT?BR)= 150 TNE REg!L.ItRED SI2:E OF THE :.=.,OIL RBSORPTION SYSTEM 15;: THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF TNE TRENCH OR DRRINFIEI_[:'. ]'lqE DEPTH OF F: 'I'RENCH OR PIT IS THE DISTRNCE BETWFEN THE SURFRCE OF' THE GROUND Rt',i[) THE BOTTOM OF THE EXCRVRTION (IN FEET::'. THERE: IS NO SE]' WI[:,TH FOR ]'RENC'HES. THE GRRVEL DEPTH IS ]'HE MINIHUM DEPTH OF GRFIVEL BETWEEN THE OLITFRLL F:'IPE BND' THE BOTTOM OF' THE EXCRVRTION (IN FEET). PERMI]' F-iPF'L. ICRNT HAS THE RESPO1,,ISIE:ILITY TEl I1.,IFORM THIS DEPRRTMENT [.',URING THE: If..ISTFII._LFITION IN'::PECTION'-:.-; OF RNY WELLS RDJFICENT TO TI`lIS PROPER]'Y FIN[:, '['HE NUMBER OF RESIDE1.,ICES THFIT '['FIE WELL WILL SERVE. ............ ]-l...lC~ .:.'. 2 ]. I I'-~_~]F'EEL']:-]- I ~] ~l~-~ F:~RE R!!~LT.~I.J I: BF~CKF'ILuLINEi OF F~NY SYSTEM HITHOUT F'INRL INSPECTION I~ND RPPROYFIL BY THIS DEPF~RTMENUF WILL BE SUBJECT TO PROSECUTION. MIi'.,iIi"lUM [:,IS'FFli",ICE BETWEEN A WELL BD,tD RN"r' ON-SITE SEWFIGE [:,ISPCISFIL SYSTEM IS :1.0.~']~ FEET FOR R PRI',,,'RTE WELl_ OR :.1-50 TO 200 FEET FROM FI PUBLIC MELL [:'EPENDING UPON THE TYF'E OF F'LIE:LIC I.,,IELI_ MINIMUM [:,ISTFtNCE FROM FI PRIVATE WELL TO Ft PRI',,,'R]'E SEWER LINE IS 25 FEET RN[:, TO FI COMMUNITY SEWER LINE IS 75 FEET'. NELL LOGS RRE REQUIRED I::IN[:', i',ILIST BE RETURNED TO THE [:',EPI~RTMEN'F WITHIN -9...0 DFIYS OF TWE WELL. COMPLETION. OTHER RFQUIREMENTS MI:IY F:IPPLY. SPECIFICRTIONS Bt.,ID CONSTRUC'I'ION DIFIGRFIHS FIRE: B',,,'RILFISLE TO INSURE F'ROF)ER II'.,ISTFILLFITION. I C:ERTIFY THF1T d.: I Ri',1 FFIHILIFIR .~qI]'W 'FNE REQUIREMEN'FS FOR ON-SITE SEWERS FIND WELLS FIS :.:;ET FORTH E:Y TI-IE MUNICIPFILIT"r' OF BNCHORF'tGE. 2: I WILL INSTI:ILL THE SYSTEM IN FICCORDP, NCE WITH THE C:O['.'FS. ].~: I UN[:'ER'-:;]'FIND THFFI' THE ON-SITE SEWER SYSTEM MBY RE~?:,~IJIRE ENLFtRGEMEWF IF ]'HE RESIDENCE IS ,q!EMODELFD TO INCLU[:'E MORE THFtI.,I 4 BEDROOMS. S I GNED: ................................................................ FIPPL. I E:FINT [:,OUf3LFt~ >,~ILLRf,tT MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL. PROTECTION Pouch 6-650, Anchorage, Alaska 99502 276-222'/ SOILS LOG - PF-RCOLATION TEST ~ SOILS LOG [] PERCOLATION TEST DATE SLOPE ' ~' - ~TE PLAN 10 11 d~ ~./~ l/~1~ ~L ~¢'~/~ WAS 6ROUND WATER ENCOUNTERED? Gross Net Depth to Net ,.Time Time Water Drop 12 13 14 15 17- 18- 19- 20- PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT .~,/.,,:,?.'.-,¢. :. '/,4; /~'_~r_-. ,¢'n ~...,.~._ .~./v x4'. L2 ~¢,=-_.~/rj¢ 72 008 (7/76) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Ancllorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAl.. INFORMATION Complete legal description Location (site address or directions) 4501 Property owner Mailing address Lending agency Day phone Day phone Mailing address Agent I_Z~n Hnn?~h/¢00-1 RFAITV Day phone_ Address ~600 De. naZi, Suite. 400, Anchorage, A£~ska 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 5 TYPE OF WA'rER SUPPLY: Individual well XXX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- · lng 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. 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. Name of Firm Address Engineer's signature 17034 Eagle Ri,vet Leo~ Rea~ Ne. 2~ Phone Date DHHS SIGNATURE ~_ ^pproved for ~) Disapproved. Conditional approval for bedrooms. 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) 8ad( MOA ~2~  Municipality of Anchorage Department of Health &Hurnan Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~-~L~ :~=~ Parcel I a A. WELL DATA type ~__'~%i~,}~'~/If A, B, or C, attach ADEC letter. Well Log present (Y/N) L/ Date completed Total depth_ ~ ! 2~- Cased to_ 2 ! I Sanitary seal (Y/N) ADEC water system number _ Wires properly protected (Y/N) FROM WELL LOG Date of test ~' - 2 Static water level ~ ~ _ Well flow Pump level L) J~' _ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot [OC> / oo Absorption field on lot Public sewer main Public sewer service line AT INSPECTION I-f'l ~-, ".~-- ~1. g.p.~ g.p.m. ; On adjacent lots On adjacent lots Public sewer manhole/cleanout Petroleum tank ioo i- WATER SAMPLE FtESULTS: Coliform ...~A~'-~,'?~-C~r~ Nitrate ,~,~.~.'~.~o/'t)f (/~,¢2,) Other bacteria ~- ~#'D Date of sample: '~-'¢/I-ffl Collected by: B. SEPTIC/HOLDING TANK DATA Date installed J / ~ ~.~ -~)'D Tank size I .~'©O ~t~J/o,~ Cleanouts (Y/N) __ t~ Foundation cleanout (Y/N) High water alarm (Y/N) /'~//¢1 Alarm tested (Y/N) Date of pumping ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot_ ( DZ% 'f- .On adjacent lots / DO 'l~ To property line__ !O '~' Absorption field Surface water/drainage / ~ "~ Compartments ~ Depression (Y/N) Foundation Water main/service line 72-026(Rev 3/91)Front MOA21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed ~ Manufacturer Size in gallons N'~'%, Manhole/Access (Y/N) Vent (Y/N) __ __'~_ump on" level at "Pump off" level at High water alarm level J'O %-~A Cycles tested __ _ Meets MOA electrical codes (Y/N) '~. SEPARATION DISTANCE FROM LIFT s'r~ON TO: Well on lot On adjac%s Surface water D. ABSORPTION FIELD DATA Length ! ,Oc~' 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 Total depth Cleanouts present (Y/N) Date of adequacy test for If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot [ 0 To building foundation On adjacent lots Surface water Curtain drain Onadjacentlots ! O0 '¢- Propertyline I To existing or abandoned system on lot J / Cutbank /k.) /& 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. Signature Engineer's Name Date S & S ENGINEERING 17034 Eagle River Leop Road No~, Eagle River, Alasl~a ~957Z HAA Fee $ / Date of Payment Receipt Number 72 026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number LAD INGTRUCTIONS for RUSHorder # 36784 Date Report Printed: AUG 1 91 @ 10:20 ChemLab Ref, # ;?13807 RUSHorder :G6764 Client Acct :GNSENGP Collected tJUL 31 91 @ 16:15 Received :JUL 21 91 @ 16:37 Promised :AUG 2 91 hfs. Analysis Completed : Laboratory Supervisor :STEPHEN C, EDE Releaeed By : hre, Client Name tS & S ENGINEERING Ordered By ;R. SHA~R Preserved with :AS REQUIRED PWSID :UA PREI,IMIHARV Client Sample ID:L134 HANLEY G/D Sample ROUTINE SAMPLE COLLECTED BY: Remarks~ C~emDab Extraction Analysis Analyst Sample# Test-Parameter Method Units Result Date Date Signature End of Sample~ I Lab Instructions on RUSHorder# 36764 I Tests .For this Sample, ~ MUNICIPALITY OF ANCHORAGE ~ ~ .. {'e~-'~'~/ Department of Hea th & Human Services ~'~. ~,'¢. - ~:'~,~-;~.,J DIVISION OF ENVIRONMENTAL SERVICES ~ ~ 343-4744 ~ CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVA~OF ' ' ~/O WATER FACILITY FOR SINGLE FAMILY DWE~'{~G .... ON-SITE SEWER AND Parcel I.D. ~ ~,//) ~ ~/~:~/~ HAA~ ~'~ ~ ' 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) ~ot 134; Section 15; T12N; R3W Location(address ordirections) 4501 East 104th, Anchoraqe, Alaska (b) Property owner Mailing Address ___ (c) Lending Institution Mailing Address AHFC t122333 Telephone: (home) Business WA ~85747 Telephone (d) Real Estate Company and Agent . 200]. REALTY/Helen Morrow Address 2600D~na]i, ,quite 400, Anchorage, Alask~ 99503 Telephone 276-2001 (e) Mail the HAA to the following address: (or check here ~, if hold for pick up.) List contact person and day phone number below: ~ ~q EN¢~NEE~G./694-2979 Eag~r~ Ala~ qqs17 2. TYPE OF RESIDENCE Single-Family ~ Number of bedrooms__ 5 3. WATER SUPPLY individual Well~ Community ~ Public Q ,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. 72-02S(R.v ~/8~) 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, 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. Telephone ~.'~/~'z~ '2_.- ~:'~ ~'~ Name of Firm Address Date 6. DHHS APPROVAL Approved for ,~__bedrooms by . Approved /"~___ Disapproved Terms of Conditional Approval Conditional The Municipality of Anchorage Department of Health and Human Services (DH HS) 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 Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev 7/88)Back Page 2 of 2 ~ MUNICIPALITY OF ANCHORAGE (MOA) (~,~..~O~ Health Authorily Approval (HAA) k,,.~.,~// CHECKLIST- FEBRUARY 1984 .. , ~q~ 343-4744 ... ~S~ ~ Legal Descr,pti0n: ~o~ .~; ~.,~' %5-~ . A. WELL DATA~ WellClassific~_: ~:~¢~. ( ~;/~~]/~ IfA, B,C,D.E.C. Approved(Y/N)~ Well Log Present (Y/N) ~ Date Completed ~/~ ~ Yield Total Depth ~ ~' Cased to .Z~ ]_~ Depth of Grouting Static Water Level __~'L~ ' Casing Height Above Ground ~¢ Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL.: To Septic/Holding Tank on Lot / OO To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer L_ine ,tU/~ 'Fo Nearest Sewer Service Line on Lot Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) '/ ; On Adjoining Lots / (DO ¢' ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by ~'¢ -""% . /:~'-~/_/O~?.~J~/hJ5 ;Date (.~, - Water Sample Test Results ~,~ ~/~y~.,~t_~> £ (~- ~.~C~ ~Cco ¢ ! ~c~ __~ ~0 j~ ~ ,_/~_ t& f6> <- Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~/- ~¢OSize /(~OD~,~,! No. of Compartments _ Standpipes (Y/N) c~ - _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/HOLDING TANK: To Water-Supply Well / C)O ~ To Building Foundation To Property Line I O ~ To Disposal Field To Water Main/Service Line__ [ O ~ To Stream, Pond, Lake or Major Drainage Course /O/~ , Foundation Cleanout (Y/N) ~ - Date Last Pumped. /O//A AJ//A ;for ' ' ,k)/~' Temporary Holding Tank Permit (Y/N) 72 026 (Rev 7/88) Fronl Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Z tD(D %/.~¢~' Type of System Design ./~m^)~' Length of Field f CDO Depth of Field / C~ Gravel Bed Thickness ~ Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Statndpipes Present (Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well /~Oo C- To Building Foundation Lot To Water Main/Service Line ( 0 f To~utback (if present) To Stream, Pond, Lake, or Major Drainage Course ^J/~, To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots Comments D. LIFT STATION Date Installed '~ Size in Gallons ~ "Pump On" Level at '~ High Water Alarm Level at P ~.~,~r~ Tested for Meets MOA Electrical Codes (Y/N) ~ Comments % Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. -% **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to ail MOA and HAA guidelines in effect on the date of this inspection. Signed , .:~ ~hNEEL'!NG Company . ~acjte ?~iv ;r, Al~ska 995~Z/ --/ ':' ~" qeer's Seal Date MOA No. Receipt No. Date of Payment /~-!7-?0 Amount: $ /'~ O ~-~'~ 72-026 [Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907)562-2343 FEDERAL TAX I.D, #92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order ~ 30625 Date Report Printed: DEC lO 90 @ L?:E6 Client Sample I9:L134 PWSID :UA Collected DEC 4 90 ~ 17:10 hrs. Received DEC S 90 Preserved with :AS REQUIRED Client Name : S & S ENGINEERING Clier~ Acct: SNSENGP P.O.~ NONE RECEIVED Req ~ Ordered By : R, SNAEER Analysis Completed :DEC ? 90 Send Repo~ts to: Laboratory 3upervisp~PREN C. ERE 1)S ~ S ENGINEERING Released By: ~/~"/~.~ 2) Special Instruct: Chemlab Eof #: 905107 Lab Smpl ID: 3 ~atYlx: WATER Allowable Parameter Tested ResuSt Unite Method Limits NITRATE-N ND(O.iO) mR/1 EPA 353.2 10 Sample ROUTINE SAMPLE. Remarks: SAMPLE COLLECTED BY RDJ, 1 Tests Performed See Special Instructions Above UA-Unavailable ND- None Detected "See Sample Remarks Above NA- Not Analyzed LT-Lees Than, GT=Greater Than TIME TIME OATE DAT t DATE 3F H:,I.T,I ~  DEPARTMENT OF HEALTH & ENVIRONMENTAL PR~i~Ii~N~Ai' ~C,O [ECTION 825 L Street - Anchorage, Alaska 99601 ENVIRONMENTAL SANITATIONDIVISION a~,~ ~ ~ ~g~}'l Talophono 204-4720 DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing, 1, PROPERTY OWNER , PHONE MAIUING ADDRESS ~OPER-FY RES1 DENT (If different from above) PHONE 2, BUYER PHONE MAILING ADDRESS 3~ENDING INSTITUTION PHONE MAILING ADDRESS 4, REAL?OR/AGENT [ PHONE ~AILING ADDRESS §:'~EGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS ~l One ~ Four ~ SINGLE FAMILY [] Two [] Five ~ MULTIPLE FAMILY E] Three ~ Six [] Other ~ WATI:R SUPPLY [] INDIViD[JAL' ' ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975 For wells drilled nrior to that date, g~ve well [] PUBLIC UTILI'FY depth (attach og ~f available. I 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** /~;~ YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTIL 1-Y 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 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3, SEWAGE DISPOSAL SYSTEM [~] INDI VI DUAL/ON -SITE [~ PUBLIC UTILITY Connection Verified []Septic Tank or []Holding Tank Size: If Tank is homemade give dimensions: NUMBEROFBEDROOMS [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATEINSTALLED INSTALLER SOILS RATING TYPEOFTANK MANUFACTURER TOTALABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line [] OTHER Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line 5. COMMENTS DATE ~'~'~PPROV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED BY 72-010 (Rev. 6/79) 825 "t_" STREET ANCttOF]AGI!, AL.ASKA 99501 (90z~2o4-41tl January 14, 1981 Carl Nevvenheim Star Route A Box 17{[6-N Anchorage, Alaska 99502 Subject: Lot 134 De~-Ha-z:t~-~-Sel-b{[i~v-i.~-~-o~'~(T12N R3W Section 15) A[.~proval for your individual sower and waher faci].ities cannot be granted until the foil.owing items have been comp] eted: k~(].) A well log subm.i, tted to this office for our review. ~(2)~ The water analysis report be(,delivered_..~ t to this oflice from the Chem Lab, 5633 B or, ce , for our r~view. If there are any ft.lrther questions please call this office at 264-4720. Si ncerely P, oberL (,. Prat. t, R.o. /Is so(: Late Specia]_ist RC P/1 j w cc: AI. aska Statebank Mortgage Loan Department 3].0 East Northern Lights BouJ. evard 99503