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Home My WebLink AboutMOUNTAIN PARK ESTATES #2 BLK 3 LT 15Mountain PaPk states lock Lot I 017-022 -27 ~ 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 NAME LEGAL DESCRIPTION z../d ILOCATION PHONE ~EW DISTANCE TO: Man u factu rer Liq. capacity DISTANCE TO: Manufacturer DISTANCE TO: No. of lines/f ]e to finish ~gth Type of crib Absor,t 4 a Inside length Dwelling Ma r e¢/ W dth NO. OF B,~ROOMS PERMIT NO. No. of ~partments Liquid depth IF HOMEMADE: Dwelling PERMIT NO. Liquid capacity in gallons We, //¢ /~, Length of each line Foundation~ ~, Total length of lines Material beneath tile Material Nearest lot Trench wid~h~ ~ inches inches Width Depth Crib Crib depth PERMIT NO. Di stan c e~.~t/$e n 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) Well DISTANCE TO: Building foundation Class Depth Driller DISTANCE TO: Building foundation Sewer line OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS ~2-0131~ ~'v. 3i7~8)~~~ DATE LEGAL DRILLING LOG Well Owner. · ~.~_~1~. Construction Use of Well Dom. Location (address of: Township, Range, Section, if known; or distance main road Size.of casing ~" Depth of Hole Static water level 190 ft. (abg~)i Screen ( ); Perforated ( · ~ '- feet Cased to 240,5 feet (below) land surface. Finish of well .(cheek one) open end ( ). Describe screen or perforation Well pumping test at 6 gallons per (h:0~t) of drawdown from static level. (minute) for ~ hours with .... Date of completion ~t -.~,~: "Tr~ WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness ? ~ Silty Gr,.ye! ); ft. TO TO .TO TO .TO. .TO .TO. .TO .TO .TO .TQ _TO. .TO. .TO. C, er~i[i¢%te No's. 814 & 973 2 ' STATE F'ERHIT NO. IF F L I _,Hlq r L r' C:FIT I ON I..EGRL 825 "L" STREET, FINCHORF:IGE, AK. 5~950:J. ~..,..! E L.. b,. F~ ~'-4 [2." i..'Et ["-.~ .-- "_2..; Z -IF E f:?,, E~.. Ibqt EEl ,:.' 7805Er==:~ ) B, EF'F;IF. LTHENT C' .-IEF. ILTN AND EN',,,']RONHENTF. IL. t ..TECTI. ON FRANI.::: E;ETHAF.:D FOSTEF: L:I._ E:Z.': HCIUNTFI:I:N F'K ESq". ~2 ~:4'4'"'- fEII2tEIE; LOT '5'i:ZE 2E~ E6~IJARE FEET "F'¢F'E OF SOIL RESZRETT-N S'¢STEH I~;: FF:.EN_.N I'IH,.,IM..fl NUHBEF.: OF E:E[::,F;.:OOf,12:, 4 / THE RE¢:!UIF::ED SI 0F THE SOIL AB'::;FF.'F'TION :-r:,TEH IL-T,: 1.2 GROUND AND THE F::CrT]-C~f'l OF THE E',:.:',CA',,,'FITZON ,::IN FEE:]".'.,. THEF.:E IS NO SET I,.II[:,TH FOR TRENCHE'S. 'T'PIE GRR',/EL DEPTH IS THE HZNIHUH DEPTH OF GRAVEL. BETWEEN '['HE OUTFRLL. PIPE AND THE BOTTOH OF THE Eh',CR'v'P'ITION ,.'.IN FEET). F'EF. ff,II'I" AF'F'L. ICFINT HAS THE REEF'ZI'-~'S]'EZI~.TT'¢ TO IIqFOF::H THIS DEPFI[4:'I'MEI'.EI" [:,UF~:]:NG THE: :[N':STALLATICd'.4 IN2;F'EZ:T]:ONS OF FIN'¢ WELl_:, A[)3RCENT TO THIS FR_FEF'I ~ AND 'rile NLH',tE;EF.'. OF F.:ESZE,ENCES.; '['NAT TFIE WELL 1.4IL. L SER',,,'E. 'T ~..-~ C~ ,:: ;.-_:,,.t ::, Z ~-~ ~S=-; F" EE C: '"IF' ::[. C, Ii"...~ ~: F-~ ~'-~" IE£ E;.~: E~ ,:~.~ #J .'t[: [-::_ E.E.. - ............... E~FIC:KF ]: LL I NG CIF F:ll",l"r' 'E,"r'~,TEH 1.41THCIL.IT F I t",IFIL I NE;F'EC'f' Z I:~l",t ANt:, FIPF'RO'v'FtL. E;"r' 1'I'"1 ]: S DEPFIF,:THEN'r WILL DE 'SUB..'rEC:T TO PF.:OSECLITION. PIINIHLIH DISTANCE BETWEEN A WELL RN[.':, AN'.t ON-SITE SEWRGE [:,ISPOSF:IL S"r'E;TEH IS :Leto FEET FOR R PF;.'.IVRTE NELL.; &50 TO 200 FEET FROH A PUBLIC WELL DEPENE:,ING UPON TNE T"r'F'E OF F'UE:L. IC WEI...L.. 4EL..L. LOGS RRE REG!U!RED AND HUST BE F-:ETUF.!NE[;." TO THE DEPFIRTHENT 1.4ITHIN 3:0 [::,R'.r'S 3F THE NELL COHPLETION. :)THER REE:!UIRENENTS J'"JA'T' FIF:'PL'¢. SPECIFICATIONS AND CONSTRUC:TION DIAGRAHS FiRE -:t',,,'RILRE,'LE 'FO INE;UF.:E PROPER INSTALLATION. I C:ERTIF'.r' THAT i: I AH Ff:IMIL. IRR I,.tITN THE RE6~UIREP!ENTS FOR ON-SITE SENER¢5 RN[) 1.4EL. LE; FIS E;E]' FORTN BV THE HUNIC!PRLI"I"¢ ,OF RNCNORRGE. 2: i WILL INE;TRLL THE Sk'STEM IN RCCORDFINCE NITN TNE COB, ES. :~:: I UNE:,ERSTAND THAT THE ON-SITE SEWER :S'¢STEf'I P'IF:I'~.' F'.EE~UIRE ENLF:IRGEME:NT IF TNE F:E:E;ZE:,ENCE IS F~EP10DEL. E[:, T)9 INCLI_!~,J f'IJ3RE THAN 4 E:E[:,ROIDHS. ............................ .___ ............. : .... ..... __..,.__: ..... :.......:_ ._ 2 CONSULTING GEOLOGIST BOX 476-M, STAR ROUT~: A o ANCFIORAGE, ALASKA 9950:/ · PHONE 344-707! SOILS LOG Performed for ~/~~ ~~[ Date ~ /6 /~~ 4 16 18 20 Soil Type Water Level Remarks '\. Total Depth of Excavation Groundwat er ~ Not Reached Depth, if Reached Classification Method Visual ( ) Sieve Analysis Material at Total Depth ~ Bedrock ~ Not Reached Depth, if Reached Gary F. Player, Consulting Geologist CONSULTi~W(; GEOLOGISt A~4CHO~]AGE, ALASKA 99507 . PHONE 344-7071 SOILS LOG -4 . $0 ~ .12 Soil Type Water Level 2O Total Depth of Zxcavation_~ C Groun dwa t er ~ Not Reached Depth, if Reached Classification Method (~ Visual ( ) Sieve Analysis A,-~yK~' '-h-~ ~en~arks Material at Total Depth Bedrock Not Reached Depth, if Reached Gary F, Player, Consultin2 Geologist Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. oz7-o22-27 COSA # Expiration Date: i/ '- 2. -3 ~// GENERAL INFORMATION Complete legal description Mountain Park Estates'#2 Block 3 Lot x5 Location (site address) xgxoz Foster Road, Anchorage, AK 9q~;x6 Current Property owner(s) Mailing address Lending agency Mailing address Scott & Carla Gage · 3zoz Foster Road, Anchorage, AK 995~6 Day phone ' 223-3456 Day phone Real Estate Agent Jim Standifor/Dynamic Properties Mailing Address gx~.x C St., Ste. xoo, Anchorage, AK U"nless oth~'rWise requested, COSA will be held by DSD for pickup. :NUMBER OF BEDROOMS: TYPE OF'WATER SUPPLY: individual WeH Individual water Storage Community Class ~ Public Water System Day phone 244-3940 4 TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] Individual Holding Tank Well [] Community On-site [] [] Public Sewer E~ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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. Name of Firm Pannone Engineering Services, LLC Phone 272-82:t8 Address P.O. Box :too2z7, Anchorage, AK 99r;~o Engineer's Printed Name Steven R. Pannone, P.E. Date [~/O~t:P Li Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the 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. PES can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized nor will it confer any legal right whatsoever. 5. DSD SIGNATURE ~'~ Approved for ¢ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: A. WELL DATA Mountain Park Estates #2 Block :1 Lot ~5 Well type P Date completed Total depth 250 ft. Parcel ID: o:~7-o22-27 If A, B, or C provide PWSID # ~ Sanitary seal (Y/N) Y Cased to 24o.~ ft. Date of test Static water level ~9o Well production 6 FROM WELL LOG q13./.13.q76 WATER SAMPLE RESULTS: Coliform ~ colonies/100 mL Arsenic: ~ ug/I SEPTIC/HOLDING TANK DATA Tank Type/Material Greer Steel Tank size ~25o gal. Foundation cleanout (Y/N) Y Date of pumping 7/28/2o~ ABSORPTION FIELD DATA Date installed 81~1~78 Length 58 Total depth ~4,/~2 ft. g.p.m. Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) [2+ AT INSPECTION 81~12o~ :t99 ft. :1.9+ g.p.m. Nitrate ~cO{ mg/L Date of sample: 8/2/;m~ Collected by: Laura Pannone Date installed 8/~/~q78 Number of Compartments _~ Depression over tank (Y/N) N Pumper A+ Home Services Cleanouts (Y/N) Y High water alarm (Y/N) N/A Soil rating (g.p.d./ft2 or ft2/bdrm) 275 ft. Width 2.67 ft. Eft. absorption area ~2o ft2 Monitoring tube Y System type Deep Trench Gravel below pipe =2 Depression over field N Date of adequacy test 8/2/2o~ Results (Pass/Fail) Fluid depth in absorption field before test 6_3 in. Elapsed Time: ~44o min. Final fluid depth 6_3 in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N Pass For&bedrooms in, Water added6o5 gal. New depth66 in. Absorption rate >= 600+ g.p.d. If yes, give date D. LIFT STATION Date installed "Pump on" level at .. in. Datum E. SEPARATION DISTANCES Size in g'~~ "Pump ofFal, at _ C c,es in. Manhole/Access (Y/N) High water alarm level at Meets alarm & c rcuit requirements? in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot ~oo+ Absorption field on lot ~oo+ Public sewer main NA Sewer/septic service line 2~;+ Animal containment areas ~oo+ On adjacent lots ,,a~.~ d/~, cO~rl~/E:E) On adjacent lots 9~ Waived Public sewer manhole/cleanout NA Holding tank ~oo+ Manure/animal excrete storage areas ~oo+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5' Property line ~o+ Absorption field ~;' Water main ~.o+ Water service line .,o+ Surface water ',oo+ Wells on adjacent lots .,oo+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~o+ Water Service line ~o+ Curtain drain None Known Building foundation ~o+ Surface water ',oo+ Wells on adjacent lots ~oo+ Water main ~o+ Driveway. parking/vehicle storage o* F. COMMENTS * Trench is under driveway. An approved (~OSA was issued in G. ENGINEER'S CERTIFICATION · I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. . Engineer s Printed Name Steven R. Pannone, P.E. Date I,.l~ ~ ~Cl/ COSA Fee $ ('~4;[0 '-- 'Waiver Fee $ Date of Payment Receipt Number (Rev. 11/05) Date of Payment Receipt Number Municipality of Anchorage Community Development Department Development Services Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On-Site Systems Approval # 111311 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 3, Lot 15 of Mountain Park Estates #2 subdivision. This inspection revealed a nitrate concentration of 6.01 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL)of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On- Site Systems Approval. SGS ReL# 1113533001 Client Name Pannone Eng. Srv. Printed Date/Time 08/04/2011 11:42 Project Name/# Mtn Park Estates #2 BK3 Collected Date/Time 08/02/2011 11:00 Client Sample ID Mtn Park Estates #2 BK3 Lot 15 Received Date/Time 08/02/2011 12:50 Matrix Drinking Water Technical Director Stephen C. Ede Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 08/03/11 08/03/11 NRB Waters Department Nitrate-N 6.01 0. I00 mg/L SM20 4500NO3-F B (<I0) 08/02/11 AYC Microbiolog~r Laboratory E. C01i Total Coliform Negative I 100mL SM20 9223B A 08/02/11 DLC Negative 1 100mL SM20 9223B A 08/02/11 DLC FOSTER ROAD N O0 03' 45" W / 10.00 mZ m-n m 10' UTILITY EASEMENT WOOD FENCE .,'4 00 03' 45" W 110.00 A+ HOME'SERV;;I, CES~_:~:~ ..-..., ................ ,.INC... CUSTOMER 7501. E. 140th Avenue Anchorage, Alaska 99516 345-1890 INVOICE # 40477 Block Lot DATE DESCRIPTION AMOUNT 07-2g ' ~"-- ~--':- "-- -~ -' , , ..... :/,,, : ....... ,, RE~AnKS " ~ ' .: .... _~allons ~ Septic ~ Leach Area ~ Holding .n, I Standpipes ~ PROBLEM AREA ~ CALL FOR MORE INFORMATION EEDS TO BE DONE MONTHS AGARS ood Shape I~ Sludge buildup on boffom ~ Floater on top ~ Jim cap missing or ~ Out standpipe to 1' above ground ~ Needs 8eptictrine needs replacing P.O. Box 196650 MUNICIPALITY Of ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHOR ITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lo~ation (Site addre~or directions) Mmhng adarbss 3 ~o r c St;, Unless othe~ise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: /7' TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: I~di~idual on-site Holding tank Community on-site Public sewer NOTE: 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 seaI aff. ixed 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 dateof this inspecti.on. Name of Firm FI~/-:,~,~ Address Engineer's signature ,'~~ DH, ,~SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments (" 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 DHH8 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 MAY ] 9 1999 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SE~¥~Y · ENVIRONMENTAL SERVICES DIVIS! Environmental Services Division ON 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: Ko J' /5-,, ~/~',~ /'//-n ?~r~ ~s'~Pamell D.: A, WELL DATA Well type /~r~ Log present (Y/N) Total depth Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level Well production If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~O / ~' / 76' Cased to '~ 5' ~. 5- ' Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION /,f / '7( 5-/tv 17~ ~' g.p.m. ~. ~ v- g.p.m. WATER SAMPLE RESULTS: Coliform (:~ col / I O C~ Date of sample: ..~--/t q ? Nitrate Oollected by: Other bacteria 2 ¢~ ///o~.~ B. SEPTIC/HOLDING TANK DATA Date installed ~/~' / 7 oF Tank size Foundation cleanou,t. ~/N) Y Dine of P~ping ~//9~F~. Pumper ~ ~ C. ABSORET!ON FIELB;DATA '~ Dat~jnstalled $/~ / 7~ ;~ 8oil rating (g.p.d./~zor.Z~d~) ~Tff ~ System~pe I ~-o~ Number of Compartments ~ Cleanouts (Y/N) 'r' Depression (Y/N) /V High water alarm (Y/N) N, Gravel thickness below pipe Monitoring Tube present (Y/N) Y' Total depth Iq. Depression over field fi/N) Results (Pass/Fail) ?~-~ For '7' bedrooms Fluid depth in absorption field before test (in.); ~ 2. ~ z~' Immediately afterJ~dg gal. water added (in.): ~ zG./y Fluid depth I ~-. 0 (ins) Minutes ater: I ~ 7' Absorption rate = G ~_C g.p.d. Peroxide treatment (past 12 months) (Y/N) h/' If yes, give date N. ~. 72-026 (Rev. 3/96)* D. LIFT STATION N./~, Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons "Pump on" level at* *Datum "Pump off" level at* Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot I o ~ ' Absorption field on lot / / '7 ' On adjacent lots On adjacent lots Public sewer main Public sewer manhole/cleanout /'J. Sewer/septic service line -~ z.C' Lift station /'~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 5" Property line I Z' Absorption field. Water maiWservice line ~ ~" Surface water/drainage ~ too ' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~ ~' Building foundation I Suffacewater ~ ~0o' ('5'¢e no,z(~ Curtain drain /'~ o,~ ~ .~ e Driveway, parking/vehicle storage area 'T'~'e,~ Wells on adjacent lots ~ / / ~ ' ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal record~.~.~.~t~b~ s are in conformance with MOA HAA guidelines in effect on this date. Signature ~~ ~ ~ Date ;~y /~, ~9~ HAA Fee $ ,~ ~ ~ ' Date °f Payment ~'/ff-~/'~O~-, ~.~ ) Receipt Number 7/ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Rick Mystrom. Mayor Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 http://www.ci.anchorage.ak.us May 26, 1999 Ted Moore, PE Flattop Technical Services 14530 Echo Street Anchorage, AK 99516 Subject: Waiver Request #WR990027 Parcel D #017-022-27 With Health Authority #HA990222 Waiver Request for well on Mt. Park Estates #2 Block 3 Lot 15 to: absorption field on lot 10 of 95 feet septic tank on lot 16 of 98 feet Dear Mr. Moore: Your request for a waiver of the required 100 feet horizontal separation from the absorption field on lot 10 to the private well on lot 15 has been approved. The approved separation distance is 95 feet. The separation distance between the private well on lot 15 and the septic tank on lot 16 is also approved to 98 feet. This waiver approval applies to the existing on-site wastewater disposal systems to the well on lot 15 only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely, Donna C. Mears, E.I.T. Civil Engineer On-Site Water Quality Program MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Wa'iver Review Worksheet WR# ~5~J~ '~ PID~ 017-022-27 HA# HA990222 Date Received: May 19, 1999 Legal Description: Lot 15 Block 3 Mountain Park Estates Engineer: Ted Moore, PE, Flattop Technical Services 14530 Echo Street, Anchorage~ Alaska 99516 Applicant: Eric/Lisa Paerels Permit Waiver Requested: Westerly end of trench on Lot 10 to private well on l,ot 10 of 95'; possible tank encroachment of Lot 16 to the private well on Lot 15 of 98' Criteria: 1. Geology: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: Special Conditions: Points: 3. Other: Waiver is Granted: List Conditions or Reasons for Date: ~ Rec ~: i~ount: Mt. Park Estates #2 Lot 14, Block 4 Waiver for 95 feet from existing absorption field to existing well. Waiver for 98 feet from existing septic tank to existing well. Issued May 26, 1999 General The well to septic tank encroachment has existed for over 20 years. The nitrate sample taken from the subject well is 4.26 rog/I, consistent with the area. Well The well was installed in September 1976 at a total depth of 190 feet. The static water level is 195 feet. The well is cased to 240 feet. Septic Tank The septic tank was installed in October 1975 and is a 1,000 gal concrete tank with jet aeration which is no longer in operation. Absorption Field The absorption field, a trench, was installed in 1995. This area is quite flat with a heavily vegitated area along the property line. It is unlikely that any potential surfacing effluent would make it's way to the subject well. ADEC Point Calculations Points Values Water Table 7.6 June 28, 1998 195 ft. Bottom of system to static water level 183 ft. Soil Sorption % of strata 1.5 silty sandy gravel 215 ft. 88% sand 30 ft. 12% points for strata type 1.5 1.5 points for total strata 1.32 0.18 Permeability 1.9 silty sandy gravel 215 ft. 2 88% sand 30 ft. 1.5 12% 1.76 0.18 Water Table Gradient 2.9 Horizontal Separation 2.8 Total Points 16.7 Vertical Separation 0 ft. Horizontal Separation 95 ft. 0.0% 95 ft. As per ADEC waiver guidelines a point value of 16.7 is almost sure to be free from any form of contamination from household sewage. CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS THEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 345-1355 ANCHORAGE, ALASKA 99516 May 19, 1999 M.O.A. DIn-tS On-Site Services P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: By means of this letter we are requesting issuance of a waiver reducing the required separation . distance between the existing well serving Lot 15, Block 3, Mountain Park Estates, Unit #2 and an existing soil absorption trench on Lot 10, Block 3 from 100 feet to 95 feet. The waiver should also approve the fact that a portion of the existing Jet Aeration tank on Lot 16, Block 3 probably encroaches to within 98 feet of the same well. A site plan is enclosed which delineates the relevant locations. Water sample test results and copies of relevant well driller's logs and other documents from your files are enclosed to assist you in your review of this request. Because the sale of this property is scheduled to close on May 27, 1999 we are requesting an expedited review of this waiver request and issuance of the necessary HAA certificate. Per a discussion with Donna, I understand that the owners of Lot 15 are not responsible for payment of the waiver fee, since the encroachment occurred after the well was drilled. According to the driller's log the well was completed on September 4, 1976 and has a total depth of 250 feet and a yield of 6 gpm. The log reports that the material between 70 feet and 238 feet is a silty gravel, which is probably nearly impermeable. During a yield test conducted on May 14, 1999 I measured the static water level to be at 195 feet below the top of the casing and the yield of the well to be in excess of 5.8 gpm. Water samples collect on that day were satisfactory, showing 0 colonies of coliform bacteria, 2 colonies of other bacteria and 4.26 mg/1 ofnitrate-N. There is no reason to believe the 2 colonies of other bacteria are indicative of septic contamination, and the somewhat elevated nitrate level is consistent with background nitrate levels encountered elsewhere in this subdivision. The septic system serving the residence on Lot 10, Block 3 was upgraded in July of 1995 by the installation ora 64 foot long soil absorption trench containing 7 feet of sewer gravel. The westerly end of this trench encroaches within the normally required 100-foot protective radius surrounding the existing well on Lot 15. The measured distance between the well on Lot 15 and the cleanout pipe at the west end of the new trench on Lot 10 is 96.5 feet. The waiver request of 95 feet is to allow for a probable slight underground encroachment .of the sewer gravel closer to the well. The enclosed soils log for a test hole dug near the west end of the trench prepared in conjfinction with the septic system upgrade indicates that the soils in which the trench is constructed are a medium dense sandy gravelly silt with a percolation rate of 48 minutes per inch. Because of the high silt content, soils of this type should provide excellent filtration of septic tank effluent as it passes through the soil. The Jet Aeration tank serving lot 16 was installed in October of 1976. The measured distance between the well on lot 15 and the cleanout pipe on the first compartment of this tank is 101 feet. Given the configuration of the tank, it is quite probable that underground portions of the tank may extend as close as 98 feet from the well. While this configuration might or might not necessitate issuance of a waiver by itself, we feel that the distance should be addressed in conjunction with the waiver to the septic system on Lot 10. Because the tank is concrete, and is located downslope from the well, it is extremely unlikely that there is any potential for contamination from this tank affecting the well on Lot 15. The ground elevation at the Lot 15 well and the cleanout pipe at the west end of the Lot 10 soil absorption trench is essentially the same. This means that there would be no tendency for effluent that might daylight from the trench (when it eventually fails) to migrate to the vicinity of the wellhead. The following is a breakdown of how waiver analysis points could be assigned in accordance with DEC's 1985 "Separation Distance Waiver Guidelines for SCRO". Category Points Distance to water table (195' -1' -11' = 183') Soil Sorption ((58' x 2.5) + (125' x 3.5))/183 Soil Type ((58' x 1) + (125' x 3))/183 Water table gradient (assume 0%, parallel to ground surface) Horizontal separation (95') 7.4 3.2 2.4 2.9 2.8 Total 18.7 Based on this point assignment, and using D.E.C. guidelines, it appears that the waiver can be granted without concern as to potential pollution of the well from the soil absorption trench on Lot 10. This finding is augmented by the fact that the aquifer being drawn upon by the Lot 15 well is very deep. Furthermore, the fact that the static water level is 43 feet higher than the level at which the aquifer was encountered indicates that the overlying silty gravel confines the aquifer. This means that the aquifer is well protected from contamination originating in the overlying soils. As noted above, even the shallow soils in this subdivision have a high silt content and thus should provide excellent filtration of septic tank effluent as it percolates through the soil. Please feel free to give me a call if you have any questions on this waiver analysis. Sincerely, Ted Moore, P.E. R 100' SOIL ABS. LOT 16 BLOCK 3 AERATION TANK SEPT I SYST. WELL~ LOT 9 BLOCK 3 (VACANT) foo'/ ~ LOT 10 ,, ,, WEL BLOCK 3 LOT BLOCK 3 ~ ,;;' ~-;5 SOIL -SEPTIC TANK WELL LOT 14, BLOCK 3 o SEPTIC SYSTEM o L15, BLK 3, MTN. PARK EST. #2 WELL AND SEPTIC SYSTEM SITE PLAN FLATTOP TECHNICAL SERVICES 1 INCH = 50 FEET 14530 ECHO STREET DRAWN BY TFM ANCHORAGE, ALASKA 99516 MAY, 1999 NOTE: THIS IS NOT A SURVEYED PLAT. ALL LOCATIONS SHOWN ARE APPROXIMATE. Parcel I.D. # 1. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section MUNI OF ANCHORAGE DIVISION SERVICES P.O. Box 196650 Anchorage, Alaska 99519~1:~NM~N~AL 343-4744 AUG 1 4 1997 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING R GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ..~x~ (.~./;<~/.¢,~,~.¢/~,.,~.~ TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 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: 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 Engineer's signature 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 ,4;~'~"¢~' ×-''-~'/~-~ · ..~ ?' Phone~ Address ¢',~¢¢z~ ~..,~¢.,.~',~-,-,~.._~ ,¢~,~. ~--¢¢-/-~-.~.~ ~.~c" ¢¢-~¢ ~ ~'k / Date DHHS SIGNATURE Approved for .¢ Disapproved. Conditional approval for bed rooms. bedrooms, with the following stipulations: Additional Comments 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. Em ployees 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 lvlUNtCIPALl~¥ OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SE~Ig~B~^~s~¥~cEs D~WStOtq Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 9950'1 · (907) ;~7~ 1997 REC Vrr. D Health Authority Approval Ohecklist Legal Description: z:~,~/~ ~'~: j'/-~.~-~.~t ,~:~.~F.5 ~ ~- ~.~ .--~-~' ~'~. A. WELL DATA Parcel I.D.: Well type ,~',~,~',,vz~' Log present (Y/N) Y' Date completed Total dep~ ~ ~ / C~ed to ~ ~. ~ s~ se~ ~ ~ ~OM ~ LOG Date of test q/~/~ S~fic water level / ~ ~ Well production ~ g.p.m. If A, B, or C, attach ADEC letter. ADEC water system number ~ / Casing height (above ground) /.5'-// Wires properly protected (Y/N) ~' AT INSPECTION d, '" WATER SAMPLE RESULTS: Coliform z~ Nitrate Date of sample: .Jo-~>/ /~' B. SEPTIC/HOLDING TANK DATA Date installed ~//~//'~'~ Tank size /3 ~'D Foundation cleanout (Y/N) Date of Pumping 7//~//q 7 -~-6/P Other bacteria Collected by: -~ ~ Number of Compartments -~ Cleanouts (Y/N) ~' Depression (Y/N) AJ High water alarm (Y/N) ~-/'~' Pumper ,~'o~-",o ,,~",o~'~_ C. ABSORPTION FIELD DATA Date installed ~'//-~./~'~ Soil rating (g:p.d./ft.2 or ft~/bdrm) .~ v' ~'~ System type Length .v----------------~ ~ Width -~--~ ~/ Gravel thickness below pipe -/-~.~ Totaldepth. Effective absorption area -'~ 7~,,~ ~Monitoring Tube present(Y/N) )/ Depression over field (Y/N) Date of adequacy test ~'~;'~/~7' Results (Pass/Fail) .,~-4~..< For .~ ~9~ bedrooms Fluld dapth in absorption field before test (in.); '~'~ 'rlmmediatelyafter?/~'gai. wateradded (in.): Fluid depth /~-~ .(ins.) Minutes later: ~' op/ Absorption rate = ,~o.o g.p.d. Peroxide treatment (past 12 months) (Y/N) .a.)~ If yes, give date D. LIFt STATION Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons "Pump on" level at* _ Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /oo '~ A-ff. Absorption field on lot Public sewer main Sewer/septic service line ; On adjacent lots ; On adjacent lots Public sewer manhole/clemmut Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation -ff",~/. Property line /0 '~ ~/. Absorption field Water main/service line ~..C' ~.Surfacewater/drainage/~O ,~fT/. Wells on adjacent lots SEPARATION DISTANCE FROM ABSOILPTION FIELD ON LOT TO: Building foundation /~'/. Surface water Cu~ain dr~n Property Line 14~ ~'d..Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots /et> F. ENGINEER'S CERTIFICATION I certify that I have determined thrufield inspections and review of Municipal records in conformance with MOA ~,guidelines in effect on this date. Engineer s N~e ~r~ ~;-'~ ~/ ~ Fee $ ~' ~ W~ver Fee $ Date of Pa~ent f)e/~ ~- Date of Payment Receipt Number~/~ 5V~/&) Receipt Number Rev. 8/95 eSS: haa.wk.doc 08/12/97 10:25 '~907 34~ 3438 5IARCIA NEWSIAN 907 ~4~ .~284 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 . CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# ¢Z)~'~ --E~-~-'~ HAA# ~'~O~'L\~-~\~-o-o~ 1. GENERAL INFORMATION Complete legal description Location(site address or directions) Prop?ty owner · ':. ~Ma, d!jqg add,~#~ Lending agency-. Mailing addrbss Agent Address Day phone Day phone Day phdn'e. Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROON~S: ~ '4 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and s, tatus of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site (/ Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. ' 72-025 (Rev. 1/91) :font MOA#21 STATEIVIENT 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 an d/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 ~"~ v~ Address ~-((,Of EngineeFs signature Phone Date DHHS SIGNATURE Approved for ,~Z Disapproved, Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: J o (~-f,~ ~V, {~-F 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 p.rofessional engineer's work. 72-025 (R;v. 1/91) Back MOA I~I Municipality of Anchorage //~ Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: 15IoL ~Cc~,{-~ .?~. ~L, F~(~-- Parcel I.D. A. Well Data ~ Well type T~v~[~-- If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) ~( Date completed ~5 ~"7~ Driller ho~ Total depth ~5'~ Cas'ed to Sanitary seal (Y/N) ~1 Date of test Static water level Well flow Pump level1 'Zqo 7--4 o-. '>~' Casing height Wires properly protected (Y/N) f FROM WELL LOG g.p.m. AT INSPECTION t - -/F MUNICIPALITY OF ANCHORAGE .%~/IP, ONMENTAL SERVICES DIVISION .',PR 2 7 1994 g.p.m. RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot ; .' ~ Public sewer main ,' ..... Sewer service line "' - ' ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate ,¢~ Other bacteria Collected by: H'~ B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) .,, High wate? al~.rm (Y/N) Date of pumping Tank size Foundation cleanout (Y/N) Compartments Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I 0 o 4- To property line [o ,~ Sudace water/drainage On adjacent lots Absorption field Foundation I o Water main/service line CONTINUED ON BACK PAGE 72-026 (3/93)* Front = Size in gallons ~ Vent (Y/N) ~evel at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARATION DISTANCE FROM LIFT STATION TO: '~ Well on lot On adjacent lots ~"Sud~ace water D. ABSORPTION FIELD DATA Date installed ~ ' ~/' ~ Soil rating (GPD/Ft2) ~.o-~ ~rv¢~- System type f Length 5-'~ Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Width "~'~-" Gravel thickness /'~ '~'.~ Total depth i(-P ~¢'~; [;~'7~0 Cleanout present (Y/N) ~ Depression over field (Y/N) ~ t~-' '7.- .~ ~ Results (pa..~.~ss/fail) '~,~ for ~z~ Bedrooms (~ After test l~./{ ~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot {.D0 4- To building foundation On adjacent lots ~JO~L Surface water )q fA-- On adjacent lots I bo 4- Property line To existing or abandoned system on lot Cutbank 100 'J~ Water main/service line Driveway, parking/vehicle storage area lb ~- Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA Engineer's Name ~)ou~/~ '"'-~', ~_.~vl~(~ Date L~.-~.~ .,¢~,.-( HAA Fee $ Date of Payment Receipt Number guidelines in effec, t~,~ .e~_ ~'~?a~ '~is inspection. Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back Douglas T. Kenley Civil Engineer State of Alaska C.E. 8176 SEPTIC SYSTEM ADEQUACY TEST Applicant Bob Michaelis Legal Description Date of Test SYSTEM DATA Tank Volume Number of Bedrooms Absorption system Flow per Bedroom Absorption required (1,5 daily flow) .~)' gallons 3 trench 150 gallons 675 gallons TEST DATA TIME FLOW VOL. TANK LEVEL TUBE LEVEL COMMENTS (gpm) (gals) 8:00 AM 10.00 0' 8:10 AM 10.00 4" 8:20 AM 10.00 12" 8:30 AM 10.00 18" 8:40 AM 10.00 21" 8:50 AM 10.00 22" 9:00 AM 10.00 22,5" 9:10 AM 10.00 700 gal. 22.5" 9:20 AM 12" 9:30 AM 8" 9:40 AM 7,5" 10:40 AM 7" 10:50 AM 6" 8:00AM next day 6" System Passed X Sysytem Failed Comments: A total of 700 gallons was added to the system monitoring tube. rise in the tube. Page 1 Douglas T. Kenley Civil Engineer State of Alaska C.E. 8176 WATER WELL ADEQUACY TEST Applicant Bob Michaelis Legal Description Date of Test WELL DATA (FROM WELL LOG) Depth 255' Static not measured Yield 10 gpm Size of Casing 6" Sanitary Seal yes Grading around well yes TEST DATA TIME FLOW STATIC LEVEL FLOW RATE (gpm) (gals) 8:00 AM 10.00 not measured 9:50 AM System Passed X Sysytem Failed Comments A total of 700 gallons was drawn from the well. The equivalent of 1.5 times the average daily flow. Exceeds FHA minimum of 3.0 gpm. Page 1 DATE RECEIVED " INSPECTION APPOINTMENTS /~)d.~/.~--/L-/~ ~_...g~..~ ~' ,/:~ TIME TIME TIME / DATE DATE DAT~-~''~ ~''PT''''~''~ INSPECTOR I NSPEOTOR. INSPECTOR vlUN~f-~ALiTY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. OF Ifi~ALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE~I~ONMENTAL [:~OTFCTiON 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISIONJUL 1980 Telephone 264-4720IiECEiV i s REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND sEWER FAClLI I DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE MAI LII~IG. A DDR ESS PR IDE PHONE ~ PHONE MA~I~NG ADDRESS MAILIN~ADDRESS 4. REALTOR/AGENT ~' I PHONE MAI LING ACD[~R ESSA 5. LEGAL DESCRIPTION STREET LOCATION . S. TYPE OF RESIDENCE ~/' ~'~' NUMI~ER OF~BEDROO [] One [] Four [] ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY ~ Three [] Six Other 7. WATER SUPPLY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) o~,.~'~ ~ 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL uSc'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 [] IN DIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []SepticTan~or E~]Ho,dingTank Size: /..2-..~ If Tank is homemade SOILS RATING give 'dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELL TO: Septic/Holding Tank Absorptio'n Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS [~APPROVED FOR ._~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY 72-010 (Rev. 6/79) MUNICIPALITY OF ANCHORAGE Mi~'~L',L~ OF ANCHOR^GE I DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIONDEPT' OF HEALTH & 825 L Street - Anchorage, Alaska 99501 ,ENVIRONMENTAL PEL~TECTION ENVIRONMENTAL ENGINEERING DIVISION ~J0V ~_ 6 1978 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~J~ DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1, PROPERTY OWNER PHONE MAILING ADDRESS PROPERTYRESIDENTlifdifferent from above) } ' ' ' PHONE 2. BUYER PHONE MAILING ADDRESS 3. 'LENDING INSTITUTION PHONE MAILING ADDRESS 4. REALTOR/AGENT I PHONE I MAILING ADDRESS JS, LEGAL DESCRIPTION STREET LOCATION ' ~ One ~ Four ~ SINGLE FAMILY ~ Two ~ Five ~ ' MULTIPLE FAMILY ~ Three ~ Six [] Other 7. WATER SUPPLY ,~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM C~ INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date /~-J..~'- ~'. If system is over two (2) years old an adequacy test is required [] PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78} THIS SIDE FOR OFFICIAL USE ONLY [)ATE RECEIVED INSPECTION APPOINTMENTS 'IME TIME ITIME )ATE DATE DATE NSPECTOR INSPECTOR INSPECTOR )IRECTiONS: NUMBER OF BEDROOMS 1. TYPE OF RESIDENCE E~ SINGLE FAMILY [] MULTIPLE FAMILY [] ONE E~ THREE [] FIVE E~ TWO [~ FOUR [] SIX E] OTHER WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3, SEWAGE DISPOSAL SYSTEM ~J INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size:.. /~,~_~"O If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4, DISTANCES WELL TO: Absorption Area to nearest Lot Line PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMITNUMeER DATE INSTALLED ~ ~_q ~ INSTALLER SOILS RATING MANUFACTUR~ Septic/Holding Tank Absorption Area Sewer Line INearest Lot Line 5, COMMENTS - APPROVED FOR ,.z> BEDROOMS ~-J CONDITIONAL. APPROVAL (letter must accompany certificate) DISAPPROVED DATE LEGAL DESCRIPTION BY(Title) 72-010 (Rev, 3/78)