HomeMy WebLinkAboutNORTH WOODS BLK 1 LT 2Onsite File
North Woods
Block 1
Lot 2
#051-731-79
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/orisite
On -Site Wastewater Disposal System Permit
Permit Number: OSP211352
Work Type: Septic Upgrade
Tax Code Number: 05173179000
Site Legal Address: NORTH WOODS BLK 1 LT 2 G:1459
Site Mailing Address: 22428 NORTHWOODS DR, Chugiak
Owner: NELSON ROBERT A
Design Engineer: FIRST WATER CONSULTING
This permit is for the construction of:
Effective Date
Expiration Date:
Lot Size in Sq Ft
Total Bedrooms:
,n�nt
DcI)artment
8/26/2021
8/26/2022
20130
2 Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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
rE
pecial Provisions: The records for Northwoods Block 1 Lot 3 indicate that the well on Lampert Estates Block 2
Lot 3 was abandoned per code. Engineer states that no well was found.
-� I0/710,t CO -&I
G.rwe
ill
fio 2
b'J room S
od6tJ
Received By: Date: /
Issued By: Date: 026 Qi�
'_
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051-731-79
Property owner(s) ROBERT A. NELSON Day phone
Mailing address PO BOX 203286, ANCHORAGE, AK 99520
Site address 22428 NORTHWOODS DRIVE, C.HUGIAK, AK 99567
Legal description (Sub'd., Block & Lot) NORTH WOODS B1, L2
Legal description (Township, Range & Section)
Lot Size 20,130 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
Fx_1
Initial ❑
Single Family (SF)
El
(w/wo ADU)
Septic Tank
El
Upgrade Q
Duplex (D)
ElHolding
Tank
ElRenewal
ElMultiple
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.
(Signature of property owner or authorized agent)
Permit/Rush Fees: $ q5
Date of Payment: g Z�Z
Receipt Number: &6' i N
Permit No. 1352
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\C lie nt Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / firstwaterAK@gmail.com
August 18, 2021
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC SYSTEM UPGRADE PERMIT
LEGAL: NORTH WOODS BLOCK 1, LOT 2
The property owner has requested we obtain a permit to upgrade the failed septic system of the
above referenced lot. We propose to install two shallow pressurized trenches and 1250-gallon
STEP tank to serve the existing 2-bedroom residence. The design is based on the recent test hole
conducted on August 9, 2021. No groundwater was observed at test hole excavation, but was
monitored at 11. Per this groundwater monitoring, the existing field will be decommissioned
and 6 vertical separation has been maintained with this proposed design.
The slopes are flat at the proposed upgrade location and moderate elsewhere 50+ away. The lot
and area are served by public and community water. The design will not impact any of the
neighboring properties. Please contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211352, Rebecca Carroll, 08/26/21
I co I 1
DESIGN CALLS: GROUNDWATER MONITORED AT 8.5'
2 BDRM x 150 GPD = 300 GPD 10/7/2021 REQUIRED DESIGN CHANGE
300 GPD/0.45 GPD/SF. = 667 SF SAS
667 SF / 5 x .64RF (2.5' ED) = 86 FT, TRENCH TO -4.5' MAX DEPTH.
USE 2 TRENCHES - 43' (L) X 5' (W) X 2.5'(ED)
TOTAL DEPTH FROM EXISTING GRADE, -4.5' 86 LF 1 1/4" PVC WITH 3/16" HOLES
@ 2,9' SPACING (TYP)
NOTES: STAKE PROPERTY LINE & WATER LINE PRI❑R TO C❑NSTRUCTI❑N
NO WELLS WITHIN
200' OF PROPOSED
SEPTIC SYSTEM
NO SLOPES >25% WITHIN 50'
NORTHWOODS DRIVE OF PROPOSED FIELD.
KEYBox N90 00'00"E 100.00'
15' LITUTY ESMT
PAVED o
D/W m
u
APPROX
WATERLJNE
/ LOCATION
O N
33.0'
E R 120' O
N 320' N
0
_ EXISTING "' LOT 2 x
x x 2BR HOUSE BLK 1
NORTH WOODS BLOCK 1, LOT 2 SUPPORT ®SERVICES:i OF ��®
PREPA
ROBERTEA NOELLSON �
22428 NORTHWOODS DRIVE ®* 9 TIH*
CHUGIAK, AK 99567 /
FIRST WATER CONSULTING DATE: 10/7/2021 /` rtis Huffman
SURVEY. JLSCE 128991
13030 SUES WAY DRAWN: FWCS
10/7/2021
ANCHORAGE, AK 99516 SCALE: 1" = 40' '%onssiols'
907-350-9566 FirstWaterAK@gmail.com PAGE: 1 OF 2
DEac DECO i
LOT 3
o MH x
LOT 1
DECOMMISSION E .N. ® MH I
W
SYSTEM k INSTALL NEW
C)
7250—GAL HDPE STEP TANK MT MTI
O
OFLAT
O
O
O
O
O
O
DECOMMISSION/
O
O
Z
EXISTING
i
FIELD
FLAT x
,1-511 I
xx
FLAT
101
ITH21—TTT.T
NORTH WOODS BLOCK 1, LOT 2 SUPPORT ®SERVICES:i OF ��®
PREPA
ROBERTEA NOELLSON �
22428 NORTHWOODS DRIVE ®* 9 TIH*
CHUGIAK, AK 99567 /
FIRST WATER CONSULTING DATE: 10/7/2021 /` rtis Huffman
SURVEY. JLSCE 128991
13030 SUES WAY DRAWN: FWCS
10/7/2021
ANCHORAGE, AK 99516 SCALE: 1" = 40' '%onssiols'
907-350-9566 FirstWaterAK@gmail.com PAGE: 1 OF 2
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211352, Rebecca Carroll, 08/26/21
4661
13030 Sues Way - Anchorage, Alaska 99516
Tel. 907-350-9566 firstwaterAK@gmail.com
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION: NORTH WOODS B1, L2
PERFORMED BY: FWCS / FWC - I CURTIS HUFFMAN CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALL STATE & MUNICIPAL GUIDELINES IN EFFECT
ON THIS DATE. DATE: 8/17/21
DEPTH
FEET OG
SOILS
1
ORG/OL
2
3
4
GM/SM
5
6
7
8
9
10
11
12
13
14
15
16
17
BOH
18
19
20
Reading Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
8/12/21 30 min 6 10/16
30 min 6 11/16
30 min 6 10/16
PERCOLATION RATE 48 (MIN / INCH)
TEST RUN BEWTWEEN 4.5 & 5.5 FT
PERC HOLE DIAMETER 6
PRE-SOAKED PRIOR TO TEST & ALL READINGS TO
THE 1/16TH.
GROUND WATER ENCOUNTERED: NO
IF YES, AT WHAT DEPTH: NA
DEPTH TO WATER AT MONITORING: 11
DATE: 8/17/21
TESTHOLE # 21-1 DATE PERFORMED: 8/9/21
SEE SITE PLAN FOR SLOPE & LOCATION
COMMENTS:
VERIFY GROUNDWATER MT
AT TIME OF CONSTRUCTION
PERFORMED FOR: ROBERT NELSON MURPH
8/17/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211352, Rebecca Carroll, 08/26/21
NORTHWOODS DRIVE
0
KEYBOX N90*00'00"E 100.00'
15' UTILITY ESIVIT
PAVED 0
D/W (6
O N
(D Lo
)ECTO 12.0' CD
32.0'
EXISTING c'
C�
X X HOUSE _X—X—XI
44.0' 33.5
LOT 1 DECK X LOT 3
0 SEPTIC X
VEN T LIJ
.W (typ) ^
0
(D
CD
0
0
0
b X
0
LOT 2 X
BLK 1
X
< X FND."-)/8" REBAR
AS-BUILT OF:
NORTH WOODS SUBDIVISION ANCHORAGE RECORDING DISTRICT, ALASKA
LOT BLOCK PLAT 79-195
SURVEY CERTIFICATE: 1, John L. Schuller. Have conducted a AWF • O.F NN -s"
L LAND
A
or
physical survey of this property as shown on this drawing and that the 10... ..� t •S� P,
improvements situated hereon are within the property lines and no• ;0e
enchroachments exist other than noted. Under no circumstance should 0,00 0!49TH .7
j p'�
any information on this drawing be used for construction of fences, ?, * - 1, * :::�
.................
structures, improvements, or f 'A I -
or establishing boundary lines.
PA FA
.. . . •... •.....
EXCLUSION NOTES: It is the owners responsibility to determine ?j ......% -
the existence of anv easements. covenants. or restrictions which -JOHN L. SCHULLER.-* 0
7,
LS-10408
do not appear on the recorded subdivision plat. tx -
1831 Talkeetna Street
WORK ORDER NUMBER:— DATE: SCALE. E—MAJL
11 0 ' . 'j., _A
MAY 12, 2021 1 =30' schullerftk.net Anchorage, Alaska 99508
21-039 DRAWN BY: CHECKED BY. GRID NUMBER: BOOKTPA(3F—ss,oMW (907) 227-1455 office
JLS NW1 459 210153 (907) 274-4992 fax
NAME
'~-' 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
MAILING ADDRESS
LEGAL DESCRIPTION
[] UPGRADE
LOCATION
__. v DISTANCE TO:
~-~- 2 Manufacturer
~I- Lq
tO0o
Absorption are~
DISTAN£
JEer
DISTANCE TO:
No. of lines
Top of tile to finish grade
Length
IF HOMEMADE:
Type of crib
DISTANCE TO:
DISTANCE TQ:
Crib diameter
Depth
Building foundation
NO, OF BEDROOMS5
Dwelling NO.
Inside length Width
No, of compartments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
Foundation/~) I.~... I Nearest lot line/~_~ I PERMIT NO. i~,./~.~1~/ I,
Total length of I
Material beneath tile
Depth
Trench width Distance between ~/~.,
~ Oinches Total e, f eot i v~.~.~p~, ~
inches
PERMIT NO.-- ·
Crib depth Total effective absorption area
Building foundation Nearest lot Ii
Distance to lot line
PERMIT NO.
Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING -
INSTALLER
REMARKS
APPROVED ~ ~
72-~ (~ev.~/78) -
DATE LEGAL
F'EF..'M I T ~I'-,I0.
RF'PL I CRNT
LOF:RT I L-iN
LEGFI[_
':;TE',,,'EN L. .:,l...h U-~:, L-L N:,T
NOR1-HHOE~DS [:,R I ",,'E
L2 B:I. N-JRTHHO0--:'S --,. E.
B L ,::, D.,
F'. O. -r'
C:Hi_ICi I FIK
LOT .=, I z.E
¢""-" ' tS
'TYF'E OF SOIL FIBSORF'TION =,'r:,TEII ' B'F.:FI!NFIELD
MR::.:: I MUM NLIMBER AF BEB, ROOMS= 'q'::
2C~C'~OC'~ S..':,URRE FEEl"
SOiL F.:RTINI"-; ,::SC! FT,-"BF.:)= tSE~
THE REQLI I RED .... ':; 'r ZF OF TFIE SO I L --AF'"::'FIE'PT-.-, _ ..._ _ I ON -:, T .= TEH I S:
[:, [£ F" T F! == ~-2; L_ E ~'-,~ C-~ 'T- 114 =: :~; Cci ~3 F: R "-,," E L [-", E F' --IF ~-'t =1=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFiELD.
]'HE DEPTH OF F4. TRENCH OR PIT IS THE DISTRNCE BETHEEN THE SURFRCE OF THE
GROUND RND THE BOTTOM OF THE E',,.,',CR'v'RTION (IN FEET).
THE GRR'v'EL PEP'TH IS THE t',!IN!f,IUI"I DEPTH OF GRRVEL BETHEEN THE OLITFRLL PIPE
RND THE BOTTOM OF THE EXC:R'v'RTtON ,.'.'IN FEET.'.,.
F'EF.:I',II'F RF'F'LICRNT HAS ]"FIE F.E=,FufI_,IE, ILIT'T' TO INF-IRM THIS [:,EF'RF.:TMENT DLiRING THE
INSTRLLRTION INSF'ECTIOI'-,IS OF FINY.' HEI_LS R[:,JRCENT TO THIS F'ROPERT'T' FIN[:, 'T'F{E
NJMBER OF REL:;IDEI'.,ICES TI-IRT THE HELL HILL SER',,,'E.
BRIE:KFILLING OF FINY .:,m_-,'fEl'l HITH]ILIT FINFtL INSF'ECTION RN[:, HFFF._,t L. , THI:,
DEPRF,::TMENT. . IlqIL..L BE S_E TEL-T TO F'F'CSEC:LITICIN.
MINIMUM DIF;TRNCE 8ETHEEN R HELL. RND RNY ON-SITE SEHRGE DISPOSRL. SYSTEM IS
'J. LU'tE~ FEET FOR R PRI',,,'R]-E HELL OR .±SEd TO 2gR FEET FROM tR PUBLIC HELL DEPEN[:,ING
UPON THE TYPE OF F'UBLIC HELL.
MINIMUM DISTRNCE FF.'.OM Ft PRI'v'RTE HELL TO R PRI',/RTE SEHER LINE IS 25 FEE]" RND
TO R COMMUNITY SEHER LINE IS 75 FEET.
OTHER REQUIREMENTS MRY RPPLY. SPECIFICFITIONS RND CONSTRUCTION DIFIGRFIMS RRE
RVFI!LRBLE TO INSURE PROPER INSTRLLRTION.
I CERTIFY THFIT
· 1_: I RM F'RMIL. IRR HITH THE REQUIREMENTS FOR ON-SITE SE,HERS RND HELLS RS SET
FORTH B",," THE MUNICIPRLITY OF RNCHORRGE.
2: I HILL INSTRLL ]'PIE: SYSTEM IN RCCOR[:,RNCE H!TH THE CODES.
~:: I UNDERSTRND THRT THE ON-SITE SEHER SYSTEM MRY REC!UIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELE-B' TO INCLUDE hlOF.:E THRN 2-: BEDROOMS.
RPF'LII_-.:I:tN~ STEVEN L. S~,.3::.; L-:ONST.
Russell Oyster
694-2774
O & E EN~.NEERING & DEVELO~-/MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Earl Ellis
SOIL LOG 688-2280
Performed for: Name: -~'~",~{./'Z~/~f L, ~'/Z.~;:S' ~o/w'£~', Tel. No. ~)~
Legal Description: Lo ~ ~. / ~ ~LO ~/~_. /, /LJO/~.:7-/4 V'~'"o c~ t::,
Depth (feet)
Soil Characterlsllo~' -
7__
8__
9
15
Ground Water Encountered: Yes >"No 'If yes, what depth
Proposed Installation: Seepage Pit Drain Field
Comments:
Performed by:
PLOT PLAN
PERC. TEST
/0 /
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 2; Blo¢~ I; Northwoods Subdivision
Location (address or directions)
22428 Northwoods Drive
(b) Property owner
Mailing Address
(c) Lending Institution
Mailing Address
Diana Conyers
2900 Boniface #148~
Telephone:(home) 688-3914
Anchoraqe, Alaska 99504
Telephone
Business
(d)
Real Estate Company and Agent AURORA PROPERTIES/Nancy Stahle~
Address P.O. Box 671923, Ch~.qiak, Alaska 99567
Telephone 688-4939
(e)
Mail the HAA to the following address: (or check hereY~, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING/694-2979
17034 Eagle River
Eagle River, Alaska
2. TYPE OF RESIDENCE
Single-Family,~[
3. WATER SUPPLY
Individual Well []
Loop Road. Suite 204
99577
Number of bedrooms
Community O0 Public []
Note: If community well sYstem, must have written confirmation from theSta~e Department of Environmental
consei-vation atteSting t'0'th legality and status. ·
4. SEWAGE DISPOSAL
On-site.IX ' Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
Ascert[fied by my seal affixed hereto and as of the validation date shown below, Iverifythat 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 flies 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.
Address
Date
Name of Firm ., ,~ _; ~..~;!; ~:!~G Telephone
~, ::'3:::::, i~,21,~ River Loop Road No, 204
6. DHHS APPROVAL ~J
Approved for ~ bedrooms by _4~-~/~ _
Approved ~ Disapproved __ __ Conditional
Terms of Conditional Approval
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph S 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 DHHSdonotconductinspections
or analyze data before a certificate is issued. The MunicipalityofAnchorageis not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA) ~
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: ~.c,x' '7.- ~'~.,,/.- \
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Date Completed
Depth of Grouting
If A, B, C, D.E.C. APproved~;~N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot '7..-~c,'
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
; On Adjoining Lots
~-'L~O'~- ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~ ?~'~ ~o~ Size ~ No. of Compartments
Standpipes~N) '~ Air-tight Caps (~N)
Depression over Tank (Y~
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
'~ Foundation Cleanout~N)
Date Last Pumped '~ - ~ - ~ \
r'~l~-- ;for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line bO ~'~
To Stream, Pond, Lake or Major Drainage Course
Comments
To Building Foundation
To Disposal Field
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed L~ ~ ?...,ct - G&
Width of Field ~ t
Square Feet of Absortion Area
Depression over Field (Y~
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field Lc'
Gravel Bed Thickness
/,~/'¢ Statndpipes Present 4~)'N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well '~.o o' ~"
To Building Foundation \ c>~ ~
Lot ¢ 1 A-
To Water Main/Service Line
To Property Line ~
To Existing or Abandoned System on
; On Adjoining Lots ?-.~z2
To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Dimensions
Manhole/Access (Y/N)
"Pump On" Leve~6h'a~ "Pump Off" Level at
High Water Alarm Level~
Tested for ~~g Cycles during Adequacy Test,
Meets MOA Electrical Codes (Y/N~.-
Comments ~ "'""'"'"'-'"'~
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effe,c.t.OQ t,h..e date of this
inspection ..... -':: !!'7;"~' ,! ~ '~,,..
Signed ..... ' c,~5:d N<';
· ; 5q ,::.~,~jiv, Rivor Loop i~olld No. 20.4
Company E~¢~ ~ilw,', Alaska ¢)~Y~
Date ~ / ~¢ ~ /
72-026 (Rev 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
\_/ D~.. ~ RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT~IRONMENTAL. p~OTECTION
825 L Street - Anchorage, Alaska 99501 ,
( ) ' ENVI RONMENTAL SANITATION DIVISION ,/'~ U u
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1, PROPE~Y OWNER PHONE
M~NG ADDRESS ~
PROPERTY R~SIDENT (If different from above) ~ PHONE
' ~ PHONE
2, BUYER
MAILING ADDRESS
MAILING ADDRESS
~A[LING
5. LEGAL DESCRIPTION
I TR EET ~-OCATI ON --
~0E OF RESIDENCE - ~ '
~GLE FAMILY
~ MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [] Four
[] Two [] Five
[~re e [] Six
[] Other
7. WATER SUPPLY
[] INDIVIDUAL*
~'~MMU NITY
[] 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.)
8. SEWAGE DISPOSAL SYSTEM
~INDIVI DUAL/ON-SITE~
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
INGLE FAMILY [] ONE j~'~ THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
~1~'- COMM U N ITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED ~
[]PUBLIC UTILITY
Connection Vorified INSTALLER
[]Septic Tank or F3FIolding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL 'FO:
Absorption Area to nearest Lot Line
5. COMMENTS
/~"~ APPROVED FOR ~I~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY