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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P,O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920205
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:GEERTS ROBERT E
OWNER ADDRESS:PO BOX 6720'74
CHUGIAK, AK 99567
DATE ISSUED:
EXPIRATION DATE:
PARCEL ID:05109210
LEGAL DESCRIPTION: T15N R1W SEC 8 LT 66
PAGE 1 OF 1
8/03/92
8/03/93
LOT SIZE: 108900 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IlS FOR THE CONTRUCTION OF:
WELL SYSTEM
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 (18AAC72) AN[) DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
EMERGENCY WELL PERMIT.
ABANDON OLD WELL IN ACCORD WITH AMC 15.55.
PROVIDE STATE~u~T CONCER~iNG ABANDONMENT WIT}{ WELL LOG.
RECEIVED BY: . ~A/~
ISSUED BY: .~ ~ ~
DATE:
DATE:
LOT .Szr I
I
I
LOT (./7.
I
LeT 2.
'1 ~ ~,.. '~ ,
........., ""5
I
G"' ',,TIER ANCHORAGE AREA BORO'-'~H
HEALTH DEPARTMI-'NT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
N? 651
INSPECTION REPORT ON-SITE Sf-~WAGE DISPOSAL SYSTEM
SEPTIC TANK:
MAILING
ADDRESS ~/~/~J/
LEGAL DESCRIPTION~ ~-'
DISTANCE FROM WELL_
//2
LIQUID CAPACITY_ // ..... __GALLONS, INSIDE LENGTH
SET:PAGE SYSTEM: SEEPAGE PIT:(..../-zx/.zT,~.~.¥.:~z.~,.x~.~,¢z~-/4~-:/z~ .//
NUMBER OF
MATERIAL t~/~//:~'~' ,/-~:',."~-.~ COMPARTMENTS
INSIDE WIDTH '~
/
NUMBER OF PITS / _OUTSIDE DIAMETER_ OR WIDTH ./~,~<-~
DISTANCE PROM WELL
NEAREST LOT LINE__~
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
LIQUID/-
DEPTH
LENGTH_/~'''~ ,OEPTH ~" '
BUILDING FOUNDATION~~7~'~ /~-
sq. FT.
TILl--- DRAIN FIELD:
DISTANCE FROM/WELl / .--/~i, F OU N'~'6'~
NUMBER OF LINES"_ DISTANCE BETWEEN LINES\
AB~EA SQ. FT, LENGTH OF E~H LINE
DEPTH: TOP OF TILE TO FINISH GRADE
, NEAREST LOT LINE
TRENCH WIDTtf
DEPTH OF FILLER MATERIAL BENEATH TILE
WELL:
T y p E ~'?.,-,~/z -z~-~/~ , DEPTH.
LOT LINE //~ [~ NEARESI ~/- SEPTIC
, SEWER LINE. /~ , lANK.
TOTAL LENGTH
, OF LINES
_~----IN~.~A L EFFECTIVE
IN. ABOVE TILE__
DISTANCE FROM WATER ..~
-, BUILDING FOUNDATION, /~ /~'~ _SAMPLE_/~'"~ , NEAREST
~.~ / SEEPAGE / ~Gc~ -~'~--~---'
., SYSTEM__ /~2~ CESSPOOL ~SQ~
DIS'rANCES:
DIAGRAM 01: SYSTEM
APPROVED C~ ~r.~.. /'~
HEALIH AUIHORIIY
GREATEI
327 Eagle St.
ANCHORAGE AREA
HEALTIt DEPARTMENT
Anchorage, Alaska 99501
ROUGH
279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION 8,, PERMIT
RESIDENCE ADDRESSE~ Va t1~ f~ ~) Ca- - LOCATION OF INSTALLATION~'~"~k ~C-~ bffV~
APPLICATION TO INSTAl. L: SEPTICTANK_~ , SEEPAGE PIT ~ ,DRAIN FIELD ,OTHER.
TO SERVE THE FOL. L0WlNGFACILITY. ,~ ~-A~¢¢~ G~ ~e' -
PEaOOLATm~ TEST RESULTS ~ .~,~ ~. ANT~OmATED ~A-rE o~: COMPLETION.~ / ~ BELOW T0 BE FILLED OUT BY HEALTH DEPARTMENT
THIS iS TO SERVE AS ._~q m
,
_AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED ?
_. SEPTIC TANI( SIZE Z_,~ D . T Y P E ~-~(~Lk'Yl-~;'~"f'.SEEPAGE AREA- - DIAGRAM OF SYSTEM
DISTANCES:
Health Authority
I certify that I am familiar with the requkements of Greater Anchorage Area Borough Ordinance No, 28-68 and that the
above described system is iii accordance with said code.
LOG OF DRI'~ lNG by A & L DRILI,:"G COMPANY
KIND OF FORMATION:
FROM .......... Zt ........... FT. FROM ........................ FT.
"; '"'
FROM.....'~2 .............. FT TO ~ .4 .... FT. ~ : ......... FROM ........................ FT.
FROM...~-:.[ ............ FT. TO / 2T. "'" ' FROM ......................
FROM .......... :i .......... FT. TO...f..Li. ........... FT.....~* ( .............. FROM ........................
/ ( : 'T I ,"~ FT ~";"I' ' FROM ........................ FT.
FROM-...: ................. ~ . TO .................................................
: . .- .... ~,. ¢ d~7~%
FROM.....z...:: ............ET. 'ru ......................... .................. FROM ........................ FT.
FROM ................. FT. TO ................. FT ...........................
FROM ........................ FT.
FROM .......................FT. TO ................... FT .........................
FROM .......................FT.
TO ...................... FT ............................
TO ....................... FT .............................
TO ..................... FT ............................
TO ....................FT ............................
TO ........................ FT ...............................
TO ................... FT ...............................
TO ........................ FT ...............................
TO ........................ FT ...............................
DRILLER'S NAME . .5..i[ ...............................................................
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
GENERAL INFORMATION
(a)
(b)
(c)
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name /'~/"/ /~ff~/ Telephone: Home
Applicant Address . ~"~ /
Applicant is (check one): Lending Institution []; Owner/builder,C~; Buyer []: Other r-I (explain);
(d) Lending Institution
Address
(e)
(f)
Telephone
Real Estate Company and Agent
Address
Telephone
Mail the HAA to the following address:
'TYPE OF RESIDENCE.
Single-Family~ Multi-Family I"] Other
Number of Bedrooms
WATI-'R SUPPLY
Individual Well ~ Community [] Public []
Note: If comm unity well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~ Public [] Community F'] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Fnvironmental Conservation
attesting to the legality and statua.
Page 1 of 2 72-02§ (11/84)
EI~tGINEERING FIRM PROVIDI INSPECTIONS, TESTS, FILE SEARCH, C -~ 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,
NameofFirm ,?~ ~' /~- Telephone ~-- ~3 0
Address ~' ~ ~7/,~ ~ ~/~/~ ~/~ ~
/
Engineer's Seal
Approved for ~/,-,~.~¢_~,~-,~edrooms/.~ by ..... Date
Approved ~ Disapproved
Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHE[P) 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 aot responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72~025 (11/84)
' MUNICIPALITY OF ANCHORAGI~
ENVIRONMENTAL SERVICES DIVISION
F E B 2 5 1987
RECEIVE[)
MUNICIPALITY OF ANCHORAGE (MOAJ
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY t984
264-4720
Legal Descrleuon:
gE .CZllC, ~' 7-/
WELL DATA
Well Classification I ¢~ , ¢~ ~ If A, B. C. D.E.C Approved (Y/NJ '/"/
Well Log Present (Y/N) _ ,)/ Date Corn Dieted __ '~/~c~/~, Yield
Total Depth _ / ~ <7 / Cased to
Static Water Level _ ¢/ /--?7,
Casing Height Above Ground
Electrical Wiring n Conduit (Y/N)
Separauon Distances from Well:
'¢'~/vK'~°~"f ~ Deptl~ of Grouting
TAg~ ~/+17¢:. Pump Set Al
· /~'" Sanitary Seal on Casing (Y/N)
/V
/ Depression Around Wellheac [Y/N) _
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line.
Cleanout/Manhole /'./
Water Sarnp~e Collected oy _:~'7-.¢.,./~,-z
Water Sample Test Results
On Adjoining Lots
,
/~-~ 3-: : On Aojoining Lots
To Nearest Public Sewer /k/,~
To Nearest Sewer Service Line on
/ --
B S E P T I C/I'{'t~bDl NG~I'-A NE DATA
~;/,/
Date JnstalJed l
Standpipes tY/N)
Depression over Tank (Y/N) _ ,
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Size
Air-tight Caps (Y/N)
/,,/
//¢O -~ NO. Of Compartments ~/,7~ZI~' {I )
,Y Foundation Cleanout (Y/N) /%4/
Date Last Pumpea ~/2-1/~ y
/'~ for
~ Te~ porary Holding Tank Permit (Y/N) ~
Separation Distances from Seotic/Holding Tank:
To Water-Supply Wel
TO Property Line ]
To Building Foundation _ Z/f~,
To Disposal Field ~- ~'-
Tc Water Main/Service Line
Course /~,/~ '
To Stream. Pond. Lake. or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ,~)-v~ F~ //
Width of Field ! 2Ix/)/~'A
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well / ~T-~
TO Building Foundation .~r
Lot
Length of Field
~f ~ x,9 ~- ~ &,¢ Depth of Field
Gravel Bed Thickness ~.. r~7-
'~',/~', 1,~" Standpipes Present (Y/N)
Date of Last Adequacy Test ~ ~/~1,/~'~/''
To Water Main/Service Line ~/~(¢ /
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
/
To Property Line ~'~¢ ¢
To Existing or Abandoned System on
; On Adjoining Lots ~' /d2d~ /
To Cutbank (if present) //'T/,,''¢"
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed.~ ¢¢' "~¢"~Dat e ;;~'/~L ,~'/
Company :~' ~'7'~ /"Y' ~' / MOA No.
Receipt No. ~/ d:~O / ~
Date of Payment c~"°'2'~"--/¢c~ ~
/c:) d~. ~ Engineer's Seal
Amount: $
Page 2 of 2
72-026 (11/84)
~ ~ .~CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
=-- Dri' ' TELEPHONE (907) 562-2343 5633 S Street
nkingWaterAna]ysis Report forTota Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
PU,L,o WATER SYSTEM ,.D., Z I I I Ill
PRIVATE WATER SYSTEM
Name Phone NO.
Mailing Address
City State Zip Code
Mo. Day .Year
SAMPLE TYPE:
~ Routine
[] Check Sample (lot routine sample
with lab ref. no,
[] Special Purpose
.) [] Treated Water
J~ IJntreated Water
SAMPLE
NO. LOCATION
Time Collected
~ollected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
/~Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to Indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received
Analytical Method: Membrane Pilter
* No. of colonies/'100 mi.
Analyst
Lab Ref. No. Result*
l~'~-,~e I FFo~
I ~F~
J ~-]
.J CF]
I CF]
BACTERIOLOGICAL WATER ANALYSIS RECORD
REAl) INSTRUCTIONS
BI:FORE
COLLECTING SAMPI.E
Membrane Fillefl Direct Count
Verification: LTB
Final Membrane Filter Resu~s.,
TNTC := Too Numberous To Count
OB = Other Bacteria
_BGB
· Date
Time:
Coilformll00ml
~) CoiHorm/lOOml
i
I LOT Z.
·
I HE~EBY CERTIFY THAT I HAVE ~URV[YED THE fOLLOWING
~ DESCR~eED P~0PERTY, LOT_66 BLOC~ H/~ , ~'1~ 8¢
PREClEN~, ALASKA, AND THAT THE IMPROVEMENT~ SITUATED
IHEREON ARE WITHIN THE PROPERTY LINES AND DO NOT OVER-
NO IMPR~E~[NTS ON PROPERT~ LYIN5 ADJACENT THE[~TO EN' '
,RI~ATER 3NCIIORAGE AREA BOROUGI-,
[.IEAL[Dt DEPgR~,ENT
327 EgGLE STREET
ANCHORAGE, ALASKA 99501
279-251.1
INS1 E(,~ ~Y
REQUEST FOR APPROYAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
FOR
__l/lq
Property Owner Phone
Number of Bedrooms ,~ ~'
Well Data:
C. Size
D. Construction__
B, Bacterial Analys~s
A. Septic rank (If homemade, show
Approval Request for Se Ii IVater Facilities
Page Two
B, Seepage Pit
1. Size
2. Lining
C,_ Disposal Field
1. Number of Lines
2, Tota] Length
7. Required Measurements
A. lqell to Septic: Tank
B. Well to Seepage Pit
C, Well to Se~er Line
D. Well to Property Line
E, Well to Other Possible Contamination
Poundation to Septic Tank
G. Foundation to Seepage Pit
Seepage Pit to Property Line
8, CO.lENTS:
AP P ROVE D:
DATE:
~.~PJ{__OV__AL VALID FOR ONE YEAR FROH DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT
EDllTO