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Home My WebLink AboutELMORE BLK 1 LT 9 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: _OSP 161157 PID Number; 018-171-55 Dwelling: ❑N Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New F0 Upgrade Name pg HANSCAM ABSORPTION FIELD Site Address 4301 Shoshoni ave, ANCH AK ❑ Deep Trench 0 Wide Trench ❑ Bed ❑ Mound Dhnnc ❑ Other LEGAL DESCRIPTION ELMORE BLK 1, LOT 9 Number of Bedrooms Soil Rating Total depth from original grade 1.2 GPDISF 4 Depth to pipe invert from original grade Gravel depth beneath pipe Block Lot Range Section SEPARATION DISTANCES To Septic -rom Tank Absorption Holding Field Well 100'+ 100'+ I Surface Water 100'+ 1001+ Lot Line 1 0'+ 10'+ Foundation * 10'+ 0' i 1.0 Ft. 3 Ft. Fill added above original grade Gravel length T+ Ft. 58 Ft. Gravel width Beds: Number of tines Distance between lines 5 Ft. Ft. Sewer Total absorption area Number of trenches Dist. between trenches Line 500 Ft' Ft. JOt�- TANK ❑ Septic 9 S.T.E.P. ❑ Holding ❑ Other Manufacturer r.,,..,,.:_ FT STATION mber of compartments Gal. Remarks ANCH TANK 1 500 Gal Alarm location Electrical installed by NW CORNER RISING SUN ELECTRIC Installer PIPE MATERIAL House to tank 3(}34 drainfield Tank to MIKE N ANDERSON, P.E. 3034 Drainfield 3034 COWT 3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 102 it Inspdeaci Sn 1v 7/22/16 2� 7/23/16 Location and description 3m 4'^ TOP OF TANK MH ON-SITE WATER AND WASTEWATER SECTION APPROVAL Eni��s Stamp Conditional Approval: Date Septic Approved \ /�7 Date Note: this approval does not include well permit requirements. sv 05/02118) O F �...................... ✓I MICHAEL N. ANDER50''J y 1 N ��'%'. CE 44 Permit No. OSP161157 Page 2 of 2 Municipality of Anchorage 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 Legal Description: LOT 9, BLK 1 ELMORE S PID No.: 018-171-55 MARK A B c01 50 21 TC01 51 22 TCO2 52 26 MT1 41 60 MT2 52 110 MT1 MT ® BENCH, TQ� Of MH TCO2 \ 1 / TC01 f_N� \ C01 A Hi/ i / 3 \ HOUSE I \ / -100 WELL ADI S I �, I I I � I � 1 1 / SCALE: 1"=50 TCO2 ®®®�� O(— MT2 MT2 I 0 _100 AV ® ®®® iTL1FR FABRIC tS FT_ _I.B OR 49 TH •• • srrn iaox OP0"I uu ••••• LLON TANK 91 -•MICHAEL N. •ANDERSON:S CM/SM 84 ®®®� '•,•• N0. CE 9469 92AA •.• 4-2-22 �.• ®®®�® SEPTIC SECTION NO WATER ® B4 MAY 2016 t N.T.S. OL`®®®® ® �®l{ ~,,!? GRE~,, ER ANCHORAGE AREA BOR,,~GH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LEGAL D ESCR,PT,ON J ? NAMI LOCATION SEPTIC TANK: DISTANCE ~$ FROM WELL INSIDE LENGTH MANUFACTUR ER~, INSIDE WIDTH. NUMBER OF MATERIAL ~ __COMPARTMENTS LIQUID DEPTH LIQUID CAPACITY~/~,~"OGALLONS. TILE DRAIN FIELD: DISTANCE FROM WELL/'~Of fO /' TOTAL LENGTH FOUNDATION NEAREST LOT LINE OF LINES NUMBER OFLINES f DISTANCE BETWEEN LINES ~/t/~ TRENCH WiDTH ,~iN' TOTAL EFFECTIVE ABSORPTION AREA ~/~ SQ. FT. LEITH OF [ACH LINE ~ ~- DEPTH: TOP OF TILE TO FINISH GRADE ~ / DEPTHOF FILTER ~/ ~ ~ MATERIAL BENEATH TILE ~BOVE TILE IN. TWyEpLEL~_~ "~CONST RUCT ION BUILDING NEAREST FOUNDATION__ LOT LINE_ CESSPOOL OTHER SOURCES APPROVED DISAPPROVED NEAREST SEPTIC SEWER LINE TANK REMARKS DEPTH SEEPAGE SYSTEM DISTANCE FROM: DISTANCES: INSTALLED BY: ~ SEWER LINE DEPTH: PIPE MATERIAL:--~7~ DIAGRAM OF SYSTEM LOT SLOPE: REMARKS: Form EQ-032 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECT~ON 825 'L' STREET, ANCHORAGE, R}(. ~95~1 I~LL Rt~D ON--5 I TE 5ENER PER/d RPPLICR~IT .TIM 8LIMGRPD~JFR SAR BOX 474E ~, LOCATION SHOSHONI ST LEGAL L9 BI ELHORE SUBD LOT 5ZZE 4~See SQUARE FEET TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT?BR)= 105 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: DEPTH= l~_~..-l~E-~I~--~-= :~6 GR~EPTH=x 6 / THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION <IN FEET). THERE IS rio SET ~IIDTH FOR TRENCHES. ~ THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). REQU I RED SEPT I C TRr~K _'i:: I ;:'E= '1 ~5~1 GRLLOr~$ ~T~,~O ( 2 > I t~SPECT I 0~$ ARE REQU I RED .'BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION ArID APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETHEErl R WELL AND ANY ON-SITE SEWAGE DIS~POSRL SYSTEM IS t00 FEET FOR R PRIVATE WELL OR 200 FEET FOR R PUBLIC WELL WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER I NSTRLLAT I ON. PERIl I T VRL I D FOR ONE ~r'ERR FROrl ISSUE I CERTIFY THAT i: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I HILL INSTALL THE SYSTEM IN RCCORDRNCE WITH THE CODES. ~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THB4 4 BEDROOMS. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorlge, Alaska 9950:2 276-222~ SOILS LOG -- PERCOLATION TEST [,] SOILS LOG [] PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: J/~/"~.~ /~- ,, 77 LEGAL DESCRIPTION: ~L~,~ ~ /~ It") ~ ~ / ~"/-..A~~-,~ SLOPE . SITE PLAN, · - 2 3 ~n~ ~/ 4 8- /O~ ~ WAS GROUND WATER 11 - ENCOUNTERED? 12- 13 Gross Net Depth to Net Reading Date Time Time Water Drop 16 17- 19- 20- PERCOLATION RATE .(min.utesllnch) TEST RUN BETWEEN FT AND . FT CERTIFIED BY: ~u~)e/~//~--~f/"4~'-' ,~ DATE:~ 72.008 {7/76) MOENING-GREY & ASSOCIATES, INC. GEOLOGISTS AND ENGINEERS May 31, 1977 I','JNICIPAUTy OF -' , JUn~'~ 1~:'7 RECEIVED Municipality of Anchorage Department of Health and Environmental Protection 825 "L" Street Anchorage, Alaska Attention: Mr. Les Buchholz Re: Revised Seepage Area Requirement, Lot 9, Block 1, Elmore Sub- division. Gentlemen: During construction of on-site sewage disposal facilities at the above mentioned lot, soil conditions were found to differ from those encountered in earlier soil tests. Our inspection of soils exposed in the trench now brings us to revise the previous recommendations for seepage area. Our conservative estimate based upon visual examination is 220 square feet per bedroom. This confirms our telephone conversation of this date and allows the builder to proceed with the installation. Very truly yours, MOENING-GREY & ASSOCIATES, INC. HJM/1 v MUNICIPALITY OF ANCHORAGE q Development Services Department \\ j Phone: 907-343-7904 On -Site Water & Wastewater Section - Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 018-171-55 1. GENERAL INFORMATION Expiration Date: 7-11/-2-2-- Complete legal description ELMORE BLK 1 LT 9 Location (site address) 4301 SHOSHONI AVE, ANCH, AK Current property owner(s) HANSCAM Day phone Mailing address SAME Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Private Septic Z Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ -6 �0 Date of Payment 3/3 [ z2 I Receipt Number. 031 qq0 COSA # 0,5 C Z 21 I 1.5 Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 3-22-22 .o c. •• �e 49tH �;`� '.'• ', 8. DSD SIGNATURE P••••••••.••• System #1 Approved for 4 bedrooms �• • • , ... VO MlCHAEC N. Ah�ERSC;J System #2 Approved for bedrooms CE -9469 Disapproved �� .0s Conditional approval for bedrooms, with the following stipulatio)�1�!J Original Certificate Date: - I,-/ 2 Z The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet r . � Legal Description: ELMORE BLK 1, LT 9 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled *1977 Total depth 97 ft Cased to 97 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 3128/22 Parcel ID: 018-171-55 Structure served by this system Well production at time of test 3.2+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 3.42 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 3/28122 Static water level at beginning of test 61 ft. Comments * OWNER HAD NEW PUMP INSTALLED AND DISCOVERED THE DEPTH B. TANK DATA Age of tank(s) 6 years Tank type/material SepJ"' Measured operating fluid level in septic tank 4811 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 3/28/22 D. ABSORPTION FIELD DATA Which system tested (date installed) 7/22x16 ❑ ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced 0 gallons Comments/Deficiencies: COSA Checklist yellow sheet C. LIFT STATION ❑ Required maintenance completed Age of lift station 6 years Lift station material STEEL Comments: TANK IS NEW Adequacy test date 3/28/22 Results Q Pass For 4 bedrooms Fluid depth prior to test 0 in Water added 600+ gal New depth 0 in Elapsed time 1440 min Final fluid depth 0 in Absorption rate 600 gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Yes if No Septic Tank/Lift Station on Lot > 100' If absorption field is under driveway comment below Property Line > 10'[]✓ Community Sewer Manhole/Cleanout > 100' if No ❑✓ Yes if No ft Q Yes if No ft Neighboring Tank > 100' Q Yes if No ft Private Sewer/Septic Line > 250 Yes if No ft Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' R Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' Q Yes if No ft ❑✓ Yes if No ft Community Sewer Main > 75' ❑✓ Yes if No ft Manure/Animal Excreta Storage > 100' — n Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5' Q Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Q Yes if No ft Private Wells > 100' []✓ Yes if No ft Water Main > 10' _ . ✓I Yes. if No .. ft Community Wells > 200' Yes . if No it Water Service Line > 10' 0 Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Yes if No ft If absorption field is under driveway comment below Property Line > 10'[]✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' ❑v Yes if No ft Water Service Line > 10'[]r Yes if No ft Community Wells > 200' El Yes if No ft Surface Water > 100'✓Q Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that 1 have determined through held inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet � R ��• MICHAEL N. ANDER W �; C 9 b9 •Kf ry t� N tZi h hC6 3:: 5' BASIS OF BEARING N89'46'30"E 208.71' (R&M) 10' UTILITY ESMT 0 M ® SEPTIC VENT (typ) MH 12.0' 12.0' r s ~ h O ° C a EXISTING c' GARAGE 2.5' LOT 9 BLK 1 (N Q O GRAVEL. h 0 71 O 2.5'x5' FP CANT .`L' 4 O b m N N89'46'30"E 208.58' (208.71' R) b SHOSHONI AVE ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: ELMORE SUBDIVISION LOT 9 BLOCK 1 PLAT P-635 SURVEY CERTIFICATE: I, Join L. Schuller, Have conducted a this AZW OF ,A.ZN '' "' physical survey of property as shown on this drawing and that the , • ., improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance should4{3' information any on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. k �........... i ....... L . :... +A EXCLUSION NOTES: It is the owners responsibility to determine'. ' :' ' ' 'r ' ' . • . • • • ' • • • • • • • • • • • the existence of any easements, covenants, or restrictions which o -.JOHN L. SCHULLER.- 0 do not appear on the recorded subdivision plat. IPLS-10408 q'® a WORK ORDER NUMBER DATE SCALE -MAIL MAR 22, 2022 1'=30' schWteroak net Nav �°° �. • �eZmaGJ`�` ® AAZW \'o� 22-018 en CHECKM a G D MUMS& ecrac Ate JLS SW3036 220144 �/ °fessiono\ ®, 5.0. FlHUTCH HUTCH 58.6' n LSU. vz� S P U Cn n n 1831 Talkeetna Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax MUNICIPALITY Development Services Department a mmom On -Site Water &Wastewater Section Phone: 907-343-7904 Fax: 907-343-7997 Owner Septic Tank: -Sludge level inches Lift station: Lift Station/Pump Vault Maintenance Log Street Address 14 *Pumping: required es o 'Pumping completed ygs no *Pump basket cleaned es no *Control floats cleaned es no Operation satisfactory es no Alarm System_ -Effluent filter cleanedes no *Proper.float settings. confirmed Q no -Dedicated electrical alarm circuit es no *Audible and visual alarm inside dwelling es no ,Alarm system operation atisfacto not satisfacto Manhole Riser *Ground water intrusion at riser to tank connection Les go *Ground water intrusion around pipe penetrations -Manhole lid: Functional e no 'WEep hole functional es no Insulated 6 no Properly SecuredoeOtherno -All manufacturer required inspections and maintenance completed 6 no Comments: Qualified Maintenance Provider: Technician (,rtij W. Company Signature Date of maintenance j ^ GENER L'N OR T, ON ! n (a) Legal Description (include lot, block, subdivision, section, towgship, range) Location (address or directions) .----. ~._~l~~ / - ..,.~,,.:_~.- (b) Applicant Name ~ l .~,~0_..~'"%)~/~,,'~ Telephone: Home ~ Business Applicant Address "~ (c) Applicant is (check one): Lending Institution []; Ow_..~.~builder~; Buyer r-I; Other [] (explain); ., (d) Lending Institution Telephone Address (e) 'Real Estate Company and Agent : Telephone (f) I~lail the HAA to the following address: . . , _ _ .... 2. TYPE OF RESIDENCE Single-Family/~,, Multi-Family [] Number of Bedrooms ~ Other 3. WATER SUPPLY Individual Well J~ Community I-I Public I~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsitej~ Public[] Communityl-I Holding Tank[] Note: If/community well system, must have written confirmation from the State Deparlment of Environmental Conservation attesting to the legality and status. 72-025 {11/~4) Page 1 of 2 ENGINEERING FIRM PROVIDINg..o',ISPECTIONS, TESTS, FILE SEARCH, DA 0.. 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. Name of Firm -~J ~'/'~7~.~ '~/'-~'~'<~-'/~-",~//Z~,~c"~ei~el~hone v~'~'~' / ~ ~ DHEP APPROVAL . Approved for~2._ bedrooms by Approved ,,./',.~% .~. Disapproved Terms of Conditional Approval Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 engineers work. ' Page 2 of 2 72-025 (11/84) RECEIVED WELL DATA MUNICIPALITY OF ANCHORAGE (MO.; HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: ~~'. Well Classification p~,'3 [ L~o~ ~ If A, B. C. D.F-.C. Approved (Y/N) Well Log Present (Y/N), ~ Date Completed Yield · ? "~ Deplh of Grouting Total Depth ~f 7 Cj~sed to Static Water Level - ~; Pump Set At Casing Height Above Ground / ,~ // Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) .~ Depression Around Wellhead (Y/N) Separation Distances from Well: / ~ TO Septic/Holding Tank on Lot / / -~ : On Adjoining Lots To Nearest Edge of Absorption Field on Lot ]~// (~;OnAdioiningLots To Nearest Public Sewer Line ,~//~ " To Nearest Public Sewer Cleanoub'Manhole ,A,/' ;~4' To Nearest Sewer Service Line on Lot Water Sample Collected by -_~/' "~-- _.~'~_ ~/'~=' ; Date ./_~ ,/~,'~ Water Sample Test Results ~ Comments ~ B. SEPTIC/HOLDING TANK DATA Dale Installed Size /~ No. of Compartments Standpipes (Y/N) ~* Air-tight Caps (Y/N) y Foundation Cleanout (Y/N) Depression over Tank (Y/N) /~ Date Last Pumped -,~ -- ~ Pumping/Maintenance Contract on File (Y/N) ~./~ ; for Holding Tank High-Water Alarm (Y/N) ~t/.~ Tem~ra~ Holding Tank Permit (Y/N) ~paration Distances from ~ptic/Hold~ Tank: ~ To Water-Supply Well ~ / ~ TO Building Foundation TO Prope~y Une +~ ] ~ To Dispo~l Field /~/ ~ TO Waler Main/~ice Line ~ ~ To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026{11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Str.~la Date Installed ~/~:~/? Width of Field 3' ~) Square Feet of Absorption Area Depth of Field //' ~) Gravel Bed Thickness 7 Standpipes Present (Y/N) Depression over Field (Y/N) Date of Last Adequacy Test Rasu.s of Lest Adequacy Test To Existing..~._Abandoned System on ; On Adjoining Lots J~:~ / ~ To Cutba. nk (if present) /r~,~:~ ,~ ~ Separation Distance from Absorption To Water-Supply Well / ,rv~/ TO Building Foundalion '~-~/ Lot TO Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, P~rking Area, or Vehicle Storage Area Comments L"'~/~. (b~,4· D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Waler Alarm Level at Tested for Electrical Codes (Y/N) Comments '° Check Permitted Bedroom Rating Against HAA Request *' I certify tha~ I have c .hec ke<~/er~i.ed, or conformed to all MOA and HAA g uideline~p,.~ffect on the date of this inspection. Receipt .o. Date of Payment Amount: $ Page 2 of 2 MUNICIPALITY OF ANCHORAG,~ DEPARTM~'r OF HEALTH AND ENVIRONI,1E~]L PROTECTION 825~-L Street, Anchorage, Alaska 99501 224 or 225 '~q-2511, ext. #1: Time '_~m. ~: Time ~3: Time / Date 7-2~-77 Th~ur~/ Date Date Insp JKenned¥ / Insp Insp 1. Lending Inst ~tion Request: Alaska National Bank of t~e North / _ 2. Mailing Ad[/~s: Calais II, 3301 C Street Phone: Property Fner: James Bumgardner Phone: Mazlin, ess: _Sta__r.R~uteAB~ 474E 99507 / 3. Leg~ ~escription: Lot 9 Block I Elmore Subdivision 4: Single Family Residence: Number of Bedrooms: Four Multiple Family Residence: ( ) Number of Bedrooms: ® Well System: 'Permit ~ Construction Individual well (x) Community/Public System ( ) Depth of Well 100' Well Log on File Bacterial Analysis ( ) Sewage Disposal System: Permit ~ Septic Tank Size Absorption Area On-site System ~ Public Utility ( Installed 1977 Installer Manufacturer Soils Rate Material Distances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line P~C Two ~ Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 9 Block 1 Elmore Subdivision Comments: Affadavit Attached proved Dlsapprove~: Letter Attached: ( ) Da to: Department Worksheet: