HomeMy WebLinkAboutGREAT LAND ESTATES #2 BLK 3 LT 3Onsite File
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Certified Drilling Log
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BILL Sc COLE
LLIVAN WATER WELLS
CIPO. Box 670269, Chugiak, AK 99567 688-2759
OWNER OF LAND: Anthony & Kerri Epple
ADDRESS: 23736 Big Sky Dr. Chugiak, AK 99567
Bore Hole Data
Depth
From To
LEGAL DESCRIPTION Great Land Estates #2 Lot 3 Block 3
DATE: 4-17-19
0
2
PERMIT NUMBER: OSP191066 DATE OF ISSUE: 3-29-19
TAX IDENTIFICATION NUMBER 05113125000
Is well located at approved permit location: ❑Yes ❑No
Method of Drilling: ®air rotary Elcable tool
Depth of Well: 400'
Casing Type: Steel Wall thickness .250 inches
Diameter: 6 inches, depth 184 feet
Liner type
Static Water Level: 162 feet
Recovery Rate 1 ® gpm gph
Method of Testing Air
Well Intake Opening Type: ❑ open end ®open hole
❑ Screened Start feet Stopped
® Perforations Start 155 feet Stopped 170
Grout Type: Bentonite Volume: 50 lbs
Depth: from 2 feet, to 42 feet
Well Disinfected Upon Completion: ®yes ❑ no
Method of Disinfection: Chlorine 50 PPM
Comments:
2
4
4
20
20
102
102
125
125
127
127
132
132
156
156
163
163
168
168
174
174
213
213
290
290
301
301
400
EF
-
Casing Stickup
Overburden
Silty Sand & Gravel w/ Cobbles
Hardpan w/ Boulders
Sand & Clay w/ Cobbles
Clay
Boulder
Hardpan & Boulders
Damp Tight Sand & Gravel
Sand & Gravel Water
Hardpan
Bedrock Gray
Bedrock Green Hard
Bedrock Gray
Bedrock Green Hard
Drillers Name: Cole Sullivan
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority.
Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation.
Matsu Borough: Department of Environmental Conservation.
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OP BILL s. G®LE
4b. ULLIVAN WATER WELLS
VP.O. Box 670269, Chugiak, AK 99567 668-2759
www.sullivanwaterwells.com
Pump Installation Log
Well Drilling Permit Number: SW OSP191066 Date of Issue 3-29-19
Parcel Identification Number: 05113125000
Legal Description
Great Land Estates #2 Block 3 Lot 3
Pump Installation Date: 4-23-19
Pump Intake Depth Below Top of Well Casing: 376
Pump manufacturer's Name: F&W
Pump Model: 4FOSA07301
Pump Size: 3/4
Pitless Adapter Burial Depth: 16
Pitless Adapter Installer: Whitters
Disinfected Upon Completion? ® yes ❑ no
Method of Disinfection: Chlorine 50 PPM
Comments: Pitless Manufacturer: Martinson
11 Pump Installers Name: Sullivan Water Wells
Property Owner Name & Address
Tony Epple
feet
hp
feet
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Municipality of Anchorage
Community Development Department
On -Site Water & Wastewater Program
4700 Elmore St. o P.O. Bon 196650 o Anchorage, AK 99507-6650 o vvwvvxnun's.qonsite a (907) 343-7904
legal Address n?31,3 W e,'jS---
Subdivision Correa i I nr�-t��eS 2 Block 3 Lot 3
T R Section Lot
On-site Water & Wastewater Program certified contractor performing the well decommissioning: /7 /f
Name: Cele SykI'IVQJ) Signature
Company: ,eta 11i �1C1 X1 l_� Qj-.0 Wel �S
Well decommissioning date: Method of decommissioning: AMC 15:55.060L1 a. ❑ b. ❑ c.
Location: Use the space below to provide a drawing of the property showing the following items;
o North Arrow
• Decommissioned well,
• Other water wells on the property,
• Two separate swing -tie distances for each well shown in the drawing,
Note: The swing -tie distances shall be measured from either permanent structures of property corners.
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�`�°"` MUNICIPALITY OF ANCHORAGE
�, �� On-Site Water&Wastewater Program \O'„,cnt `5e;
a.. `, PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 ,_
http://www.muni.org/onsite
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ryCHOR PG
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On-Site Water System Permit
Permit Number: OSP191066 Effective Date: 3/29/2019
Work Type: Well Upgrade Expiration Date: 3/28/2020
Tax Code Number: 05113125000
Site Legal Address: GREAT LAND ESTATES #2 BLK 3 LT 3 G:1260
Site Mailing Address: 23736 BIG SKY DR, Chugiak
Owner: EPPLE ANTHONY W & KERRI Lot Size in Sq Ft: 79715
Design Engineer: Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field ❑ Septic Tank 0 Holding Tank 0 Privy t1 Private Well 0 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
Special Provisions:
To close this permit please submit:
1. Well Log
2. Pump Install Log
3. Water sample results
4. Well Decommissioning Log
Received By: 6*6? Date: .47.2 - 9e3/2
Issued By: ) ./ I i, Date: 3/14 Cr
///
MUNICIPALITY OF ANCHORAGE
. , fr
Development Services Department j Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D.0511305
Property owner(s) A,4T Ny 3 V-EZ.t 2p1 e- Day phone'7' - ' (, I�
Mailing address x113 it q7l L DCbLA'ML ) K V-•� ' %1
Site address SA -03.
Legal description (Sub'd., Block & Lot)&'LS T \.gt•J9 allk; 7 n 12, D WV' 3
Legal description (Township, Range & Section)
Lot Size 111115— Sq. Ft. Number of Bedrooms ,-
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑ Initial ❑ Single Family (SF) 1
(w/wo ADU)
Septic Tank ❑ Upgrade Duplex (D) ❑
Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
• i
' '
(Signature of pro 9e y owner or authorized agent)
Permit/Rush Fees: 0225. 00 Waiver Fees:
Date of Payment: OSP: Date of Payment:
Receipt Number: 112 8/ Receipt Number:
Permit No. Of PIS l 0 f4 Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
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ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-0829
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE= : wait&
FOLLOWING DESCRIBED PROPERTY: � �� •+r� OF A(°°R
G9�1 d�,� r, ,,f/�.ri�� - T3 9 .� - DATE- ,,;1P��•t •. •• +• .'9 ,it,
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS ,���d -•-%.)-5---",
INDICATED. IT IS THE RESPONSIBILITY OF THE _ s�'':•4 C' NA, •-F
OWNERASN DETERMINE, OVENA THE OR RESCETRICTIONS
OF ANY GRID:. f � d� /�
EASEMdYTS, COVENANTS, OR RE.`;TRICTIONS �Y�✓"z6o -�
WHICH DO NOT APPEAR ON THE RECORDED SUBOI•- �t r . Duan. Mei# .r = k 0
VISION PLAT. UNDER NO CIRCUMSTANCES WOULD FB i if..-- Ls- x
ANY DATA HEREON BE USED FOR'CONSTRUCTION _ /3�-�� *t'r �,r•V. '...
_ OF FENCE LINES, OR FOR ESTABLISHING BOUND- DRAWN= ' % {�'���'#
ARY LINES. ,��� '� ` • u l •• , ...,..p.i.�
Parcel I.D. 051-131-25
Municipality of Anchor
On -Site Water and Wastewater Progra
(907) 343-7904
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Expiration Date: 9-2--1
Complete legal description Great Land Estates #2, Block 3, Lot 3
Location (site address) 23736 Big Sky Dr.
Current Property owner(s) Dean & Denise Mackey Day phone
PO Box 95 Chugiak, AK 99567
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well El Individual E
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date: iJ c2 Ill G
COSA Fee $ dJ dio Waiver Fee $
Date of Payment 51210//b Date of Payment
Receipt Number 053(1 Receipt Number
COSA# o`aLt>lt(it Waiver#
5. STATEMENT'~E. II~..~,~CT,:. ;~,, ON BY ENGINEER
As certified by my seal afl:ixed hereto and as of the validation date shown.below, I verify tha~ my investigation, based on procedures outlined
in the Cediflcate of On-Site Systems Approval Guidelines for this application, shows that the on-sita water supply and/or wataewatar
disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further veri~/that
based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-sfle water supply
and/or wastewater disposal system is(are) in compliance with all applicabta Municipal and Sta(e codes, ordinances, and regulagons in effect at
the lime of installation.
In conducting an adequacy test, ] attempt ~o provide a ~horough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations. The reported results describe the performance of the system under the conditions encountered al the time of the test,
and separation didances measured to readily identifiable features. The operational life of all wells and septic systems depend on ~he local soil
condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
bedrooms
bedrooms
6. DSD SIGNATURE
System #1 Approved for
System #2 Approved for
Disapproved
Conditional approval for __
Date 5/26/2016
~ OF
bedrooms, with the following stipulations:
.~¥'~ ' ~/.~,
-'~ ON-SITE "~'..
:~ WATER AND ~"
Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues CeC(iflcates of OmSfle Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an i~dependent 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.
ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
X
Nitrate Advisory
Arsenic Advisory
Other
COSAbluesheet_( '- :., c
If more than '1 septic system is on the lot:
COSA Checklist# ~ of ~
Structure served by this system ~
Certificate of On-Site Systems Approval Checklist
Legal Description: Great Land Estates fk2, Block 3, Lot 3
WELL DATA
Well type Private If A; B, or C provide PWSID #
Date completed 10/4/1979 Sanitary seal (Y/N) Y
Total depth 1 58 ff. Cased to 158 ft.
FROM WELL LOG
' 10/4/1979
Date .of test
Static water level 154 ft.
Well production 4 g.p.m,
WATER SAMPLE RESULTS:
Coliform Neg ,cdlonies/100mL Nitrate 3.36 .mg/L
Arsenic ND ug/L Date of sample: 5/13/2016
Parcel ID;05~1-131'25
Well Log (Y/N).y
Wires propei!y,protected (Y/N)
Y
Casing height(above ground) ~ ~o'{" ~n.
AT INSPECTION
5/13/2016
158 ft.
1.0
g.p.m.
Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Mate~:ial S(~ptic/Steel
Tanksize 1.000 gal. Number of Compartments 2
-Foundation dleanou~'iY/N) Y Depression ove~t~nk (Y/N)
Da(e installed 10/5/1979
Cleanouts (Y/N) Y
N High water alarm (Y/N) N
Date of pumping' ~'/~.7/~)[/--OPumper '~'~'~.
ABSORPTION FIELD' DATA
Date installed 10t5/1979 Soil rating (g.p.d./~ or ~/bdrm) 150 SF/BR System type Deep Trench
Length 38 ft.
Totaldepth 10.~1 fi, Eff. absorption area
Bate'of adequacy test, 5/13/2016
Fluid depth in absorption field before test 53
Elapsed Time:. 300 min. Final .fluid depth 53 in.
Any rejuvenation treatment (past 12 mo.) (YIN & typel No
Width Unk ff. Grovel below pipe 6 ft.
456 f¢ Monitoring tube Y, Depression over field N
P, esults (Pass(Fail) Pass For 3 bedrooms
, in. Water added 453 , gal. New dep~lh'~8, in.
Absorption r~te >= 450+ g.p.d.
If yes, give d¢te
D, LIFT STATION
Date installed
"Pump on" level at __ ,n.
Datum
Size in gallons
"Pump off' leveJ at in.
Cycles tested
Manhole/Access IY/N) ~
High water alarm level at in.
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+
Absorption field on lot ;~ 00+
Public sewer main 75+
. Sewer/septi(~ service line 2G+
Animal containment areas 50+
SEPTIC/HOLDING TANK ON LOT TQ:
Building foundation 5+
Water main 10+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Prooerty line 10+
Water Service line 10+
Curtain drain 50+
F.~.COMMENtS ~-
Septic system appears 80% used.
On adjacent lots 100+
On adjacent lots 100+
Public sewer manhole/clear~ou! 100+
Holding tank 1004'
Manure/animal excrete storage areas 100+
Property line 5+
Water service line 10+
Building foundation 104-
Surface water 100+
Wells on adjacent lots 100+
Absorption field 5+
Surface water100+
Water main 10+
Driveway, parking/vehicle storage '104-
PES recommends installing a 300 gal drinking water holding tank.
G. ENGINEER'S CERTIFICATION
I certify thai I have determined through field inspections and
review of Municipal .records that the above systems are tn
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven Pannone.~
Date 5/26/2016
COSA canap] st~eet_2-6-15.doc
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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
PHONE
I
NAME
[] UPGRADE
EGAL DESORIPTION
LOCATION
Well
DISTANCE TO: I
Manufacturer I t
ILiq. capacity in gallons I
DISTANCE TO: I
No, of lines ~ Length of each line
I
Top of tde to flmsh grade
Length ~idth
Type of crib Crib diameter
Well
cIa'' Depth
DISTANCE TO Building foundation
Absorption area iMateri¢lDWelling
Insidelength Width
Dwelling
Foundation
Total ~ng,~ of lines
Material beneath tile
Depth
Crib depth
Building foundation
Driller
Sewer line
OTHER
PIPE MATERIALS
SOIL TEST RATING
IMaterial
Nearest lot line
Trench width
NO. OF BEDROOMS
PERMIT NO.
No. of compartments
Liquid depth
PERMIT NO,
Liquid capacity in gallons
PERMIT NO.
Distance between lines
Total effective absorption area
PERMIT NO.
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO,
Sept c tank Absorpt on area(s)
DATE LEGAL
la
i..CICFiT i
i"!F!::-:i!H!JH f..iI.,.iI'"IE~fJ~F.: 3F EflEDFi:C,3HS :=
'i"HFi: [ .ENGI"H [::,:[ HENS): ON IRE!; THE LENG"FH ,:: * Fl [:~;E'r':, OF "r'H[-~: T[RE~-,~C*..I O1:,? DF'.F:I i i'.,fF: Z ELD.
"FH[:~ P~l:'7'[-.l OF: F! TRENCH Of~'. F:'ZT :[9; THE I)Z:STF!hlCE:: E',[ETi.,.!E[~:N THE ~;UF?.F:'RCE Of THE
G[?.OL!NO !aND, THE E:O'1"TOf"i OF THE Ei:.:',CI:a',,,'F1TION ,::~N FEE:T).
TFIFJF'.E:: !:Y NO ~;ET HZDTH FOR TD.~:NCFiE~;.
'T'iaE GF~:F¢,/EL. E:,EPTH I6 THE P!Zf.~IP'ILiH E:,I:~:F'TH OF GRF!',/!EL E',ETHE:[EN THE: (3UTFFILL. F'ZF'E:
FiHE) THE E:O'FTOH OF THE E',:.::C:Fi',,,'F~TZON ,::IN FEET).
i:::'E:~:;i:[','I I T F:IF'F'L~ i CF!NT l-tFIf:: THE: R[~;F:'CIN£~ I E~ ! L l T¥ I'F ~:~[ )7/'t.:' i' F;*H 'T'H I :~i; C, EF'FII~:'I"HE!:I",!T t3 I:;? Lr F,IG 'T'HF'
i ?.,i:5'FI':iI...LF:I'!' I Of'l t N:F:;F'ECT :' Oi",i'E; OF I::lf',!'¢ HELL.% FIE:,..)-FIC[ZNT 'T'O TH ! :.E; I::'1:~: :': F:'E[~:T'?' FIND '.'.'
Ni..!HD~EF: OF:' R..FZ:~:; :,': E:,E?',!C:E~:~; 'T'.hI61T THE Hf~:L.I... F.! .T LL.
· i?.FiC:f:::F: ILL.. i h,iG F F Ffi'-!k.' '.'5"r'E:;T[EH [,.! Z THC ] T F I NFIL. 1: N'F;PEE:T ]' Olq F'INE:' F~F:'F'F:O',,,'FiL. E:':" TF'! 'i :5
H 1( H 1{ HLtH i:::, i' %'f'F:lhiCi:::. [¢!~:'T'HEEN Ft !,~FZL. L I::IND F:!N"¢ Of',!--"% I ]% ::'E';EHFIGE [);[ S;F'Ei:~.:;FIL. :5'¢':'~;'FEFI i 9.';
"U?3 F:'E;E'T' FOR 61 F'RI'v'FFFE !-4ELL.; OF'.
].~:.)E~ "FO ;2i;-'_'~3 FE~ET F'F~:CIH F:f P!JE~L!C HEL..L [)EF:'EF!DZNG LIPON THE T'¢F'E OF F'LIE;LZC HEL. i. ....
lq?El.iL. /...f:'.,'[ii::~; f::t[.,;:E F:EQLI].'FIEL':, FIND I',iI.J:L:;'I' E:E: RETLIF'.F,I[ED TO THE E:,E:F'Fff['."Fi'"IENT Hi[THIN
OF' THE HELL (]:[:!t'"lF't..E!:']"Z
G'FHEF;: F:E(;]I..iIFitFJ{HfZ?.,i'[':~; !"1,'::~'-," F!F'F'L.'.r'. 'J:::F'EC:IFICFIT:[E!N:E; RF~[:.', CO?-4'E;T[:~:UC:"F.T.C!N E:,If::IC:iF;'.F:IH~
FF,,'R Z L.F:iE~L.E TO :[ F4~SUF:E~ F'?.OF'EF'. Z N:E;TFfl...LFI!' I ON.
i E:EF.'.T! F':h" THFIT
:L: I I::¢'t FF:!HiL. IFfR HtTH THE: F;[EGR..tIF~'.E:P!Ef",Ff'2; FOR ON.--%I"F[:: 5;[EP!EF::5 Fff.,E) HETLL:5 R~5 S;ET'
F'C)R"f'H EF.¢ 'FHE HUhfZ C):PFd_Z
;:Z: i i,.!ZLL. IhESTRL. L "rile :?¢~S;'FE?i ZN IaCCORDFINC[K HZ"rH THE COE:,ES;.
)~:: ]: Ui'.,IDE:F}:S;T'F~f.~D THFFI" 'THF: ON...-fS:i'TE:: S[S!.,.IEF;t S;?:S;TE::H F!Fi? D% (~¢...I Z F?. E: EiqL. F4F?.(SE:HF:f.,FF IF: 'THE
RF'F'L i C:FfihFF HFfRF~
~'CONSTRUCTION TEST L~B
"One Test is worth a Thousand Opinions"
2204 Cleveland Anchorage, Alaska 99503 277-0231
Perfo~ued for Mackey Construction (Dean's)
Legal Description: Lot ~ -Block 3
This Fomu reports: SOILS TEST Yes
Date ~erformed 9/24/79
Subdivision Greatland Estates
PERCOLATION TEST
Depth
Feet
Soil Characteristics
14'
2' Peat, Silt
Brown Sandy Gravel
Trace of Silt
Occasional cobbles.
Bottom of Test Hole
Was Ground Water Encountered No
If YES, What depth?
Reading
Date
Gross TJnne
Net TLme
Depth to H20
Net Drainage'
Percolation Rate Minute
Proposed Installation: SEEPAGE PIT DRAIN FIELD
Depth of Inlet Depth to Bottom of Pit or Trench
CO~CdENTS: 150 ~q. ~ ~raina~e ~re~ required per bedroom
Test Performed by
Data Certified By: CONSTRUCTION TEST LAB
Date : 9/25/79 . '
' 'ORIL[ER'S ~ATE~IAL LOG
~UNIClPALITY OF ANCHORAGE MUNICIPALI~ OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~EPT. OF H~ALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL P~OTECTION
Telephone 264-4720
REQUEST FOR APPROVAL OF ,NDIVImUAL WATER AND SE~dI~
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing,
1. PROPERTYOWNER I PHONE
De~ A, ~ackeyI 688-281
MA~UN6 ADg~ESS
Star Route~ 3ox ~ 1175 ~ C~ug~ak~ AZaska
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
De~ A, Hackey s~e
MAILING ADDRESS
same as above
3. LENDING INSTITUTION ] PHONE
. AZaska Nu~uaZ Sav~ngs 3ranc~ on ~ls~,I 274-25~1
MAILING ADDRESS
4. REALTOR/AGENT ~ PHONE
Ro~e
I
MAILING ADDRESS
5. LEGAL DESCRIPTION
Lot 3~ Blk 3~ Greatland E~t~te~
;TREET LOCATION
Big Sky Drive, Peter's Creek , Alaska
TYPE OF RESIDENCE ~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [] Four
[] Two [] Five
I~] Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
* ATTACH WELL LOG. Awell log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM E~ INDIVIDUAL/0N-SITE**
[] PUBLIC UTILITY
1979
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 NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [~] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or []Holding Tank
Size: ~ ~2)~) If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
'APPROVEDFOR BEDROOMS
E~] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY