HomeMy WebLinkAboutPREUSS #3 BLK 5 LT 4 GRL,~,~I{ ANCHUI'{A~I: Af(I:A I:IU,,:~ ~,JL~U Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME (),~-SS~ ~OOT~U MAILING ADDRESS 1~1~( ~ E,~, cf'1~'77 PHONE ~z~¢"/~'~ SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH MANUFACTURER INSIDE WIDTH MATE RIAL NUMBER OF COMPARTMENTS LIQUID DEPTH LIQUID CAPACITY_ /OOO GALLONS. SEEPAGE PIT: NUMBER OF PITS ~ DIAMETER .~"~.l OR WIDTH~/ , LENGTH ~ , DEPTH LINING MATERIAL ~lO~'~-~i ~' CRIB SIZE: DIAMETER DEPTH DISTANCE FROM: WELL BUILDING FOUNDATION L~0, NEAREST LOT LINE ~'1~ TOTAL EFFECTIVE , ABSORPTION AREA (WALL AREA) SQ. FT. ABSORPTION WELL: ~. TYPE BUILDING FOUNDATION __ CESSPOOL APPROVED CONSTRUCTION NEAREST LOT LINE OTHER SOURCES DISAPPROVED NEAREST SEWER LINE REMARKS. DEPTH SEPTIC TANK __ DISTANCE FROM: SEEPAGE SYSTEM DISTANCES: INSTALLED BY: PIPE MATERIAL: LOT SLOPE: REMARKS: Form No. LQ-031 DIAGRAM OF SYSTEM GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAl, QUALITY $330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-45~6'1 SEWAGE DISPOSAL SYSTEM -- APPUCATION AND PERMIT PERMIT NO. INSTALLATION LOCATION ~ INSTALLATION OF: SEPTIC TANK ~ TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS NOTE%THIS PEI~MIT IS NOT VALID WITHOUT SOIL TE.~T FINAL INSPECTION: 24 HOUR NOTICE REQUIRED BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. ~IAGRAM OF SYSTE~ MINIMUM DISTAI~CE~,, REQUIREMENTS FOUNDATION TO SEPTIC TANK ~/~ FOUNDATION TO SEEPAGE PIT SEPTIC TANK TO SEEPAGE PIT WALL SEPT{C TANK TO NEAREST LOT LINE. · SEEPAGE PIT .. DRAIN FIELD WELL TO SEPTIC TANK ~A~/~K~ / DRAIN FIELD · SEEPAGE PIT~f - '/ ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK SEEPAGE PIT DRAIN FIELD SEPTIC TANK, , SEEPAGE PiT , DRAIN FIELD TO RIver, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST.I.RON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PiT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. F'ERNIT biO. (.' T:'~!~;5]i:El ) F~F'F'L. I CFIIqT .]'E~;:!~; P.IOOTEN, LOCF:ITION GEORGt!']: PL.. LEGRL. LOT4 13LK5 I::.'REL.I'.E;:E'; :.::i;[:, LI]'T' :.-T:; :[ ;=.'.-!:E ;.[.ih::.:;EIEmEI '.:~.:,(.:.!IJI::IRE.i F:EE'T' H t I'.,t ]: MLli'd I} :[ STFINCE E~ETI-,.IEEN 1::1 I.,.IELL. IStl",t[.':, Riq'~.' Oi'.,I--L-'5., I TE SE!.,.tFtGE D I SPOSRL S"r'$TEM I S :.I..EIE~ FEE]" FOR FI F:'R.I',,,'F:ITE: WELt.. OR 2i'.!;:."i1:'~i I::EET FOR Ft PUBLIC F.tEL. L.. klEL. L. LOGS RF.':E RE(]:!UIRE[:, FII'.,I[:, I',IlJtE;T BE RETURNE[:, TO THE [:,EF'FIRTHENT F-!ITHIN ]i:~2) [:,F~'-r'L:..; OF THE I-4ELL COHPL.E'T':[ON. :5F'EC I F :[ CFIT I ON:E; FIN[:, C:ON:B]"I;i:IJC]' I ON [':, I F:tGF.:FIMS FIRE Ft',,,'I~ I LFIBL. E TO INSURE F'ROPER I i'.,i:E;]"F~L.L. FIT I ON. I _.EI:. I ].F THFt'T ::L: I FIM FFIHII....It::IR F-!]:'f'H 'T'HE F'F'..':¢J]:REHENT'.:~; FOR '31'..h-':':.;ITE '.E;EFIER'.E; I::IN[:, I.,.IEL. I...'.'5 I::1'.5 SET FORTH B"r' ']"HE I IJNI .[FHLII* OF FtNCHORFtGE. 2: I 1.41 EL. I 1",I~STFII...L. ]"FIE: ::';"r'tE;TEM I N FICCOF.:[:,FINC:E 1.41 TH THE CO[:'ES. eriifiei Drilli g" b~ A & L DRILLING COMPANY BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE694-2588 OWNER OF LAND ADDRESS LEGAL DESCRIPTION PERMIT NUMBER 7 DEPTH OF WELL sTATIC LEVEL OF WATER FT. 1 DRAW DOWN FT. [ 0 GALS. PER HR KIND OF CASING KIND OF FORMATION: From-- (? Ft. to From ~:-}) Ft. to From ~ ~ Ft. to :? .~;~ Ft. to From_ ". Ft, From ~ ,,i~ c) Ft. to ! -~ (i Ft. From J,;} (Ft. to Ft._ From___Ft. to__ Ft. From__Ft. to. Ft. From Ft. to__Ft. From__Ft. to Ft. From__Ft. to.__Ft From--Ft. to.__Ft From__Ft. to.__Ft From--Ft. to__Ft. From Ft. to Ft. From Ft. to__ Ft. From__Ft. to Ft.. From From From From From__ From __ From -- From -- From From From From __ From Ft. to__Ft. Ft. to Ft. Ft. to Ft Ft. to Ft .Ft. to__Ft. __ Ft. to__Ft. Ft. to__Ft. Ft. to___Ft. .Ft. to__Ft. .Ft. to Ft .Ft. to__Ft Ft. to__Ft Ft. to__Ft Ft. to Ft. ___Ft. to Ft. Ft. to Ft. Ft. to___Ft MISCL. INFORMATION: DRILLER'S NAME .' ~ < : i 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. # ~(~) - ~--~ \ - ~---~ "~ ~' HAA # ~'~ ~c~:~).¢-h~l~ 1. GENERAL INFORMATION Lot 4; Block 5; Preass Subdivision; Complete legal description Location (site address or directions) 10 I$1 George PZ~c~ Property owner Mailing address Lending agency Mailing address David Bu~rkel Day phone 10131G~.nrge P£ace.~ Eagle River, Ak. 99577 Day phone 694-7522 Agent M~'~. f ~w~'~ PHH/HOMEOUITV 400 East LaS Col~nas Boulevard Address Suite #$00 Irving, Texas 75039' Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS:- '~ % Day phone 214-506-8808 TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: Public sewer If community wastewater system, provide written confirmation from State AD£C 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 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 suppty 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 Address Engineer's signature $ & $ ENGINEERING 17034 Eagle River Loop Road No. 204 E~!e ,~;ver: AlasEa 99577 DHHS SIGNATURE Approved for Disapproved. Conditional approval for Phone Date bedrooms. 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. 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 professional engineer's work. 72425 (Rev. 1/91) Back MOA ~21 Legal Description: ~ 4 ~Z~... ~' 'i~¢-¢~S~ ~'//"~ Parcel I.D. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type ~'~-)/~¢~- Log present {~)'N) t Total depth \~2~' '\ ~' Sanitary seal (~N) If A, B, or C, attach ADEC letter. ADEC water system number ~ //~ Date completed ~- t ~,- ~ ~, Driller J~'-~ ~' Cased to FROM WELL LOG Date of test Static water level \ b'rl ~ Well flow ~- (~ Pump level ~'Z-~' ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ~ (~ ~ ¥ Casing height Wires properly protected (~N) AT INSPECTION g.p.m. .'7.~ '~ ~ c~ o ~ ~'' ; On adjacent lots \ Do ~' ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ~-~" WATER SAMPLE RESULTS: Coliform 0 c.~.~,/~ Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed {~ Cleanouts ~)N) High water alarm (Y,~_.~ Date of put, ping Nitrate ~ '~ ~r/~. ' Other bacteria Collected by: $ .% g ;NC~INI=I;RING 17034 Eagle River Loop Road No. 204 Eagle River, Alasl(a 99577 Tank size ~ ~(_~o r_~-'L.- Compartments \ Foundation cleanout (Y~ ~ .... Depression (Y~I~ -~ Alarm tested (Y/N) ~ ~'~ ~ ~". ~?.~ __. Pumper ;~._~ . SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \~, t-~.- On adjacent lots ~,~3 To propertyline ~c~ ~ ¥' Absorption field I~ t Surface water/drainage ~. o c~ Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes~ SE~FROM LIFT STATION TO: vCell on lot On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump on" level at .,-~'"~ump off" level at ~Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed Length ~. ~ Width Total absorption area Depression over field (Y/~ Results f~fai I) ~/~ Peroxide treatment (past 12 months) (YN~ Soil rating ~ o4 ')¢ lt~,~ System type Gravel thickness L~ Total depth Cleanouts present ,~N) ',/ ~ Date of adequacy test b~ ~ !. ~ .~ '-z.... for "~¢"~'~ (-"-~ ~- bedrooms I/-'~I~ ¢ ,~- If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~[~' To building foundation On adjacent lots Surface water Curtain drain On adjacent lots \ ¢~ t 4-- Property line \ ~ ~ To existing or abandoned system on lot Cutbank ~//~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S.CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. $ 8, $ ENGINEERING Signature ~'~'~°'~ '"~"~ "= .... ~ '*"~ ~""'~ N.". 204 Engineer's NameEagle River, Alaska 9957~ Date ~ ~ ~~ HAA Fee $ Date of Payment Receipt Number 72-026 (Rev, 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number CttEAIICAL & GEOLOGICAL LABORATORY A DIVIglON OF COMMERCIAL TESTING & ENGINEE~IN0 5833 B STREET ANCHORAGE, ALASKA 99518 TELEPHON[= (~07) 5~8-~843 FAX:(90?)$61-5801 Chat111. ab ~ot.t 92.2690 S~pl* ~ ? M~trl. x: ~At~ Client ~ple ID Collected : JUN 9 92 t 19145 h~l. Receite~ Pzeeer?e~ ~ith Analysis ¢oapleted : JUN 12 92 ¢lilnt A,~t :Og$1NGP ~olaa,.~ By: ~-'~4('. 8s~t ~epozts ~o: I ~eati PerfoT~d * See ~pecial In,tru~tions Ab~v* UA-Ur~y&llable ND. N~n~ De~e~t~d "See Sample ~e~a~k~ Above BO~ GlO O000000000ooO~n~n~a nnnnnnn ................. 1. General Information MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE Application Date '/ (a) Legal pescription (include lot, block~-~ubdiviston, section, township, range) Location (address or directions) ,<7 ~ ' (b) Applicants Name ~62Xc~O~. ~-~z~/~elephone - Home Applicants Address ' ' '~0 '~-~.~'~ (c) Applicant is (check one) Lending Institution ~ ; Owner/builder ~; Buyer ~ ; Other ~-~ (explain); (d) (e) Real Estate Co. & Agent Address . . o'~--,~c) Telephone ~7~ '- t~-~ Lending Institution -~?~ q~/ fc~/-~--c~ Telephone Address ~-~- · (f) Mail the H~ to the following address: 2. T_~pe of Residence Single-Family~'fi~[ Number of Bedrooms 3. Water Supply- Multi-Family~--~ Other (describe) Individual Well~ Community~--] Public ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. ~ewage Disposal Onsite~ 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. [Page 1 of 2] t 5. Engineerin8 Firm Providing Inspecti3ns~ Tests~ File Search, p~ta 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 regula- tions in effect on the date of this inspection. Name of Firm Address Date DHEP Approva~ Approved for ~_~. Approved ./~ Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPAR~fENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ~NALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 Be MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION AUG $1Q z Well Classification Well Log P~esent Total Depth ./~3-// // Cased to Static Water Level / dC / Casing Height Above Ground Electrical Wiring~ in Conduit Separation Distahces f~c~ Well: To Septic/~g Tank on Lot'' RECEIVED If A, B, C~ C, D.E.~ Approved(__Y/N_) '---- .... Dan% /,C?mp/le ted 8////~ ~ Y is 1Z ~--~f/7~ ~ '~ Depth of G~outing ~ ' ~_~/ l; Sanitary Seal on Casing~) Depression A~ound Wellhead .(.Y~ ; On Adjoining Lots TO Nearest Edge of 'Absorption Fib~d on Lot //d> / -. ; On Adjoining Lots To Nearest Public Sewe~~ Li~e'~ 4~ To Nearest Public Sewer Cleanc~t/Manhole , "~/~ ~.. TO Nearest Se~r Service.Line on Lot Water Sample Collectgd B ~ -- ~ SEPTIC/~==~NG TANK DATA Date Installed /~3~/~~ Size /~ ~ ~ No. of CQ~artments 2-- Standpipes/~N) Air-tight Caps,/N) Foundgtior} Cleanoutf~)N) Depression ove~ Tank (Y~ Date Last Pumped 9/3~/~ ~ Pumping/Maintenance Contract on File (Y~N)'~/~ ; for --/-~--f Holding Tank High-Wate~ Alarm (Y/N) ~ Teapotaz~y Holding Tank Permit (Y/N)/L~ Separation Distances f~om Septi~/~l~i~g Tank: To Water-Supply Well /~ O , To Building Foundation .~ / To P~operty Line ~ /* TO Disposal Field. /~ / TO Water Main/Servic~ Line /t///$ To Stream, Pond, Lake~ c~ Major D~ainage Co~ents [Page 1 of 2] 2-15-84 Prop¢'~ity Owner Mailing Add:,ess /-tl"'i"L"~ ';~1~1 I I"ILL~ I.)lJ II Dave And Gene Kelly S.R.A. Box 5211 u 'P' H i-I' P ONLY Phone Zip Code Buyer Address Zip Code Lendinglnsti/ulion Frist National Bank Of Anchorage Phone East Chester Branch Address Zip Code Realty CO. & Agent Century 21 Heritage Homes Phone S oR. 126Eagle River Address Zip Code Legal Description L 4 B 5 Pruess Sub Street Locatioe George Pl. Type of Residence 2~ Single Family [] Multiple Family No. of Bedrooms 3 [] Other Waler Supply ~I Individual [] Community [] Public Utility Sewer Disposal :~ Individual [] Public Utility [] Holding Tank 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). Year Individual Installed: When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION Environmental Sanilation Division 825 L Street o Anchorage, Alaska 99501 ,~ Telephone 264-4720 CERTIFICATE OF INSPECTION ON-SITE SEWER AND WATER FACILITY 1. Property Owner Dave And Gene Kelly Mailing Address S.R.A. BOX 5211 2. Legal Description L 4 ]3 5 Pruess Sub. 3. Type of Dwelling L~ Single Family [] Multiple Family [] Other *CONDITIONS OF APPROVAL Dup. Copy Origanal Copy Was Lost In Mail 4. Sewage Disposal -~] Individual [] Public Utility [] Holding Tank APPROVAL FOR ~'~ BEDROOMS [] DISAPPROVAL ~] APPROVED 5. Water Supply ~;I IndNidual [] Public [] Community (~s~ared) / THIS APPROVAL NOT VALID WITHOUT DEPARTMENT SEAL 72-023 (3182) APPLI(,/,NT FILLS OUT UPHb. H Mailing Addre~ -~? ~'~ Buyer Address Zip Code Phone Type of Residence ~ Single Family ~ Multiple Family No. of Bedrooms ~ Other Water Supply A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975.  Individual Community For wells drilled prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal  Individual Year IndiVidual Installed: Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector ( ~PPROVED BEDROOMS ~ *CONDITIONS OF APPROVAL ( ) DISAPPROVED (DA,: ~ON D~O NA~~ Soils Rating Date ~r Installed Well To Absorption Area Well Log Received ~)F Well to Tank Septic T~k Size 72-023 (3182) EXCAVATION ROBERT A. SHAFER Earl Chappell Century 21, Heritage Homes SR.Box 126 Eagle River Road Eagle River, Alaska '99577 WORK July 24, 1983 CIVIL ENGINEER 694-2979 Dear Mr. Chappetl, Reference: Lot 4: Block 5~, Pruess Subdivision ~ sewer system adequacy test was performed on the system located on 'referenced property as you requested.. The septic tank was pumped and verified to have a capacity of 1250 gallons. The seepage pit was charged with i000.gallons of fresh water and after a period of 24 hours all the water which had been added to the crib had percolated out. it can be concluded from this test that the waste water disposal system serving the four bedroom residence located on this property is currently functioning adequately. However, the system cannot be guaranteed against subsequent failures. If we may be of fur%her service, contact us. please ~o not hesitate to 'cc: Municipality of Anchorage DeDartment of Health and Environmental Protection SRB 196X EAGLE RIVER, ALASKA 99501  ~5~"L Street, Anchorage, Alas;Ca [ 279-2511, ext. 224 or 225 ~-- Date Received: ?J_l. ~2: Time May 10, 1977 Time Date Insp Insp _~ ~[~----- Insp REQUEST FOR APPROVAL OF iNDIVIDUAL SEWER AND WATER FACILITIES 1. Lending institution Request: National Bank of Alaska % Marva Mailing Address: Post office Box 3-3859 99509 Phone: 279-2506 Jesse Wooten 694-2716~ -- Phone: __ ,_ 2. Property Owner: Post office Box 663 Eagle River 99577 Mailing Address: 3. Legal Description: 4: single Family Residence: (x) Multiple Family Residence: ( ) o Lot 4 Block 5 Preuss Subdivision Number of Bedrooms: ~ Number of Bedrooms: sewage Disposa~ S~stem:ins~~e S~'~ins~J~L~~ ~~ ~ ~ Nearest Lot line ~ _ Absorption Area ~o Sewer Line __~l -~ -- %o Nearest Lot Line ~ / - e of Inspection: D E pA RTM EN%QFJ~IE_ ALT~ r~n~x~L~ C~N M E N TA L PROTECTION NeUUt:ST FOR APPROVAL oF INDIVIDUAL SEWER and WATER FACILITIES 4. Name of Lending Institution: Ma,,,ng Address:P 5. Name of Realtor or Agent: CONV. / VA FHA__ O w n e r: ~--0~O.A:;o~.~ /A.J~o Property s : d Name of Buyer'. (~ ~ /'~/~~ Mailing Address'. t0~ ~. ~ ~ DayPhone:~7~~_. Mailing Address: Legal Description:J-OT' /'~ Location: ~F~A ~_~ l~) o or .5 __ Phone: o Type of Facility to be Inspected: ~F~ No. Bdrms. ~,~ Water Supply Type of Supply: Public Utility .... Individual_~ If Individual, number of dwellings presently served ~ If Individual, depth of well. Sewage Disposal System Type of System: Public Utility Individual (on-site) If Individual, date of installation ~ NATIONAL BANt( OF ALASKA ~10R'i'0A{;~'~ !.0:\~! DEPARTMF:NT ANO, H01~AGE, ALASKA 99501 · ,M~L P~©7'~C/IC,N RECEIVED 72-003(3/76) Page'gwo Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 4 BloCk 6 Preuss Subdivision Comments: Affadavit Attached Approved: Disapproved: Letter Attached: ( ) Date: Date: Department Worksheet: