HomeMy WebLinkAboutRAINBOW BLK A LTS 2 & 3P.al*nbow
Block A
Lot 2 & 3
#001-162-96
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax. 907-343-7997
Parcel I.D. 001-162-96
Certificate of On -Site Systems Approval
Expiration Date:
l �
Legal description RAINBOW BLK A LTS 2 & 3
Site address 1036 W 22nd Ave Anchorage
Current property owner(s) Nathan Michalski
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 2/7/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory x
Other
COSA Approval_June 2022
1�1/�I UHMPAUTY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 001-162-96
Complete legal description Rainbow Block A Lots 2 & 3
Location (site address) 1036 W 22nd Ave, Anchorage, AK 99503
Current property owner(s) Nathan Michalski Day phone
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑■ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ ' 2 W
Date of Payment 9 M, % ;Z() ,9_ 3
COSA#
Waiver Fee $
Date of Payment
Waiver #
COSA Application—June 2022
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC231022
Subdivision: Rainbow, Block: A, Lot: 2 & 3
A water sample revealed an arsenic concentration of 23.7 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/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. information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org
Rainbow Block A Lots 2 & 3 001-162-96
6.2
Prior to 1960 *95+
*95+
24+ 23.7
02/01/23 Forge Engineering
63 01/24/23
*Per 2010 inspection in muni file.
N/A N/A
N/A
>
N/A
N/A
N/A
Property is served by public sewer.
Benjamin Schiller, P.E.02/02/23
N/A
N/A
N/A
N/A
N/A N/A
N/A
N/A N/A
N/A N/A
N/A
(907) 522-7773
Municipality of Anchorage
• Development Services Department
Building Safety Division „
On -Site Water 8 Wastewater Program
4700 Bragaw Street /
P.O. Box 196650/
Anchorage, AK 99519519-6650
www.muni.orglonsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 0011 A COSA# � S(' 10101-15'
1. GENERAL INFORMATION Expiration Date: — D - / O
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
RAINBOW SUBDIVISION LOT 2 & 3 /3/ oc k A
1036 W. 22ND COURT •ANCHORAGE.AK
DAN HENSLEY & JOYCE BAMBERGER Day phone
1036 W. 22ND COURT •ANCHORAGE.AK
Day phone
360-3177
SALLY NICKERSON W/ PRUDENTIAL Day phone 229-1148
3801 CENTERPOINT DRIVE *ANCHORAGE, AK 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
N
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑
Individual Holding tank
❑
Community On-site
❑
Public Sewer
N
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 samples. (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 Finn GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SURE 101 • ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 43 ho
Engineers Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described 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 soils condition, groundwater 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 the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or 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 I
Disapproved.
Conditional approval for
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
bedrooms.
oP,`y, ••....... ys'�Di
f r r ss.-
CE -795.10
bedrooms, with the fllowing stipulations:
Arsenic Advisory
Maintenance Agreements
Supplemental Engineers Report
Other
aoQ OF
ONSITE
WATERAND ; K -
WASTEWATER
PROGRAM ,.
By: A -1i Original Certificate Date: 00
c
(R. IW5)
Municipality of Anchorage
-tel Development Services Department
Building Safety Division
On -Site Water 8 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: RAINBOW SUBDIVISION; LOT 2 & 3 6-A Parcel ID: 001162;6
A. WELL DATA *PER INSPECTION BY ARROW . PUMP AND P1ELL SERVICES. SEE ATTACHED.
Well typePRrvnTE If A, B, or C provide PWSID# N A Well Log (Y/N) NO
Date completed PRE 1960 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth '95+ ft.
Date of test
Cased to '95+ ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
NO WELL LOG 5/4/2010
Static water level ft. 71 ft.
Well production 9.p -m. 5.85 —
9 -p.m -WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate()j mmg./L.Other bacteriay colonies/100 ml.
t I
Arsenic: q.J ug./L. Date of sample: 5/4/2010 Collected by: GEG Ltd.
B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER
Tank Type/Material
Tank size gal.
Number of Compartments _
Foundation cleanout (Y/N) _
Date of pumping
C. ABSORPTION FIELD DATA
Depression over tank (Y/N) _
Pumper'
Date installed Soil rating (g.p.d./ft°or
Length ft.
Total depth ft. Eft. ab
Date installed
Cleanouts (Y/N) _
High water alarm
System type
ft. Gravel below pipe ft.
ft' Monitoring tube_ Depression over field
Date of adequacy test Results (Pass/Fail)
For bedrooms
Fluid depth in abso ' n field before Lest_ tri. Water added _gal. New depth _in.
Elapsed T _ min. Final fluid depth _ in. Absorption rate >= g.p.d.
rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
"Pump on" level at in. 'Pump oft" lev_l as High water alarm level at
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots N/A
Absorption field on lot N/A On adjacent lots N/A
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
r .
Sewer iseptic service line 25'+ Holding tank N/A
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC)HOLDING TANK ON LOTTO: IPUBLIC SEWER
Building foundation Property line Absorption field
Water main
Wells on adjacent lots
Water service line Surface water,
SEPARATION DISTANCE FROM ABSORPTION
Property line
Water service line Surface water
Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that t 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 JEFFREY A. GARNESS
Date S-110/0
COSA Fee S 4110
Date of Payment Jl 0
Receipt Number � 7 9 / S
(Rev. 11/05)
TO:
Water
Driveway, parking/vehicle storage
Waiver Fee $
Date of
Receipt Number
Municipality of Anchorage
• Development Services Department
Building Safety 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
Arsenic Advisory
Certificate of On -Site Systems Approval # 101045
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block A, Lot 2 &
3 of Rainbow Subdivision. This inspection revealed an arsenic concentration
of 19.3 micrograms per liter (ug/L) for the property's well water sample.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/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. Information on arsenic is
available from the On -Site Water and Wastewater Program website
(www.muni.or /og nsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
S485
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orage Recording District, Alaska (P-51)
F SURVEY CERTIFICATION
Wy Mortify that I be" ourvey*d leo PmWy shown and described
and that few Wwonment* oltumad thereon we within tM prop -
Wand do *0 anrlop or eMracoh on adjacent property and tbdt
*rw*#nt# on ed)aasnt property er#rlop or #naeaah a* /M pmslwa
Non and that then on no roadway#, alley Nat, or other visible
*to on said property except as Indlceted hereon.
[anme6fe of regard other than teat* shown on
the plot of retard Mrs sot ow Nr*a■ anion,
otbonUe **to&
LEGEND
0 Eras cr Aluminum ccxad monument recovered
O Iron pipe and/or rebar recovered.
0 2 x 2 hub Stack recovered
• 6/8"x 30" rebar Met this survey
--#r— Fence Line (Approx. Location)
A
Dutton , �4i
S
,n Date Prepared by: R. L. BUTTON
n
/ a ..IBJC RegistomdLond dbrveyor
Q O6_2� /O (907J2T9-6200 C19XfZi,;I.SAm. A=&,rapeA'=177 .5;:/
/5%9 FB. No. ID"OHO Property of JOYCE BAMBE RGER
MAY -10-2010 11:191' FROM:
AAROW PUMP & WEII SERVICE, LLC
P.O. Box 110496
Anchorage, AK 89511
Office: (907) 346.9355 • Fax (907) 333-8976
Eagle River: (907) 622.9335
CUSTOMER JOB SITE
/o Z")r 2 a -aa -
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J L
SHWOOCE
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9
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WELL DEPTH
----
aWL
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PUMP DEPTH
PfA80N
QUANTITY
DESCRIPTION
PRICE
AMOUNT
I
�Se
l7eau. o at i O�
or c ac eY•c. D�
0
LABOR
HOURS
RATE
AMOUNT
TOTAL MATERIAL
TOTAL LABOR
WORK ORDERED BY
DATE COMP.
TOTAL
LABOR
PAY THIS AMOUNT
O
Thank You
SIGNATURE
(I Hereby Acknowledge the Satisfactory Compfotlon of the Above Described Work end agree that If above work to not paid for In 90 days I agree to allow Aarow
Pump 6 Well Service. L.L.C. the right to remove unpaid for equipment and charge for labor already performed A tabor to remove unpeld for equipment.)
TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. eA f NO0�,J SID
SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS.
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MUNICIPALITY OF ANCHORAGE lj
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL `• r
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION. -
(a) Legal Description (include lot, block, subdivision, section, township, range)
2. TYPE OF RESIDENCE
Single -Family P. Multi -F ily Other --
Number of Bedrooms
3. WATER SUPPLY
Individual Well i❑' Community 11Public 1:1
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE
OnsiteO/ /Public'p Cgmmunity ❑ Holding Tank ❑
Note: If co munity w system, must have written confirmation from the State Department of Environmental Conservation
attesting to trfeiegality and status
Page 1 of 2 72-025 (11/84)
1..,0'f
gOl>°�
Location (address or directions)
(b)
Applicant Name /" sc !," '"
Telephone:
Home Business
Applicant Address /C? '" e /1:'
(c)
Applicant is (check one): Lending Institution ❑ ; Owner/buHderq; Buyer ❑ ; Other ❑ (explain);
(d)
Lending Institution �'%��"+ � �sc�_c��rs._a�
s..
�,"-f`�:, -
Telephone
Address- /�P.«:.,�
%CT; L -a
des i/< ::,.. / ; •, is-�°
(e)
Real Estate Company and Agentwcc-
`s
Address
Telephone
(f)
Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single -Family P. Multi -F ily Other --
Number of Bedrooms
3. WATER SUPPLY
Individual Well i❑' Community 11Public 1:1
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE
OnsiteO/ /Public'p Cgmmunity ❑ Holding Tank ❑
Note: If co munity w system, must have written confirmation from the State Department of Environmental Conservation
attesting to trfeiegality and status
Page 1 of 2 72-025 (11/84)
5. ENGINEERING FIRM PROVIDi,.0 INSPECTIONS, TESTS, FILE SEARCH, U. i A 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 31
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, fu nctional 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 Odben V ck, Telephone
Address
Date
i
Ln
c,r.: •� Engineer's Seal
...6/ ••2225-E -
t971
i,
N_ 25, °
ea` p
6. DHEP APPROVAL
bedrooms b ---- . Date 2 2 B�
Approved for DUR � Y
Approved X .... Disapproved Conditional
Terms of Conditional Approval
\ `Qep
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
A. WELL DATA
/03� GII 2Z o
Well Classification R If A, B, C, D.E.C. Approved (Y/N) A41 -
Well Log Present (Y/N)Date Completed Yield g l pM �'" /022- Rg
Total Depth 11JO Cased to �n7 nM— Depth of Grouting
Static Water Level Pump Set At rja i?
Casing Height Above Ground 3 Ir Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Depression Around Wellhead (Y/N) fAL
Separation Distances from Well:.
To Septic/Holding Tank on Lot On Adjoining Lots
To Nearest Edge of Absorption Field on Lot JJL��-_; On Adjoining Lots
To Nearest Public Sewer Line e_% To Nearest Public Sewer
Cleanout/Manhole %'p To Nearest Sewer Service Line on Lot 30
Water Sample Collected by
Water Sample Test Results
Date 1n
Comments
B. SEPTIC/HOLDING TANK DATA IX
� Y
Date Installed Size
No. of Compartments
Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N)
Date Last Pumped
Pumping/Maintenance Contract on File (Y/N)
; for
Holding Tank High -Water Alarm (Y/N)
Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well l>_
To Building Foundation
To Property Line
To Disposal Field
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA ��� V P"e'Ic
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N) —
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
— Standpipes Present(Y/N)
Date of Last Adequacy Test
To Properly Line
To Existing or Abandoned System on
On Adjoining Lots
To Cutbank (if present)
Dimensions
Manhole/Access (Y/N)
"Pump Off' Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
"" Check Permitted Bedroom Rating Against HAA Request"
I certify that 1 hav check erifi6 , or conformed to all /�IOA Ind HAA guidelines in effect on the date of this inspection.
Signed / Date /a0��
Company MOA No.
Receipt No. — 1-46 A " DO LZ
Date of Payment /U
Amount: $C17 A 17 7) 3 M �S. Da
98610 1^l
Page 2 of 2 N0110310Nd W1N3WNObIAN3
'8 H11VAH 40 '1d]4
72-026(11/84) 30V40H_1NV 10 AlIIWDINnYl
i f 1
72258E
aaQ,� UNC ?-5, 1971
Engineer's Seal
INSTALLATION- REQUIREMENTS
THE WATER LEVEL N
-MORE -WITHOUT ANI
RECOVERED IN.3
)NS PER MINUTE
t 20, 1986
VA; LV _-MJANU1MS Ut-YUP7YklVLa
S PUMPED MR 30 MINUTES'
ATER LEVEL. THE WELL
#1: Time
Date
Insp
!u
MUNICIPALITY OF ANCHORAGE
DEPARTMEN OF HEALTH AND ENVIRONMENT.,-' PROTECTION
825 L Street, Anc.horaap. Alaska 99501
264-4720
Date Received: April 14, 1978
(-78
a.m. #2: Time �Q Q #3: Time
Monday Date - S to
Ins (} j in
tenative, not pai ye C
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request: First National Bank of Anchorage
Mailing Address: Post Office Box 4-2090 99509 Phone:
2. Property Owner: Norman B. Grant Jr.
Mailing Address: 1036 West 22nd Aven':
Pl.one: 279-1790
277-6682
3. Legal Description: Lot 2, 3 Block 1 Rainbow Subdivision
4: Single Family Residence: ( )
Multiple Family Residence: (x)
5
Number of Bedrooms:
Number of Bedrooms:
Four
Well System: Individual Well (x) Community/Public System ( )
Permit # Depth of Well 296' Well Log on File ( )
Construction Bacterial Analysis __
6. Sewage Disposal System: On-site System ( ) Public Utility (x)
Permit # Installed Installer
Septic Tank Size Manufacturer
Absorption Area Soils Rate Material
7. Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot .line Absorption Area
to Nearest Lot Line
0,9 Q
�jjP
Page -T'wo
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 2, 3 Block 1 Rainbow Subdivision
Comments:
11 1' _ 4._� rl. _"-0 671LU...I�. «__0A . 4 Aiuo L
Affadavit Attached: ( ) Letter Attached: ( )
ppp�rdv d ' C. k — Date:
Disapproved: Date:
Department Worksheet:
1 ssc-oee 19 gcei ; oao 0 11tlW 1tlN011tlN831N1 80d lON ooee it6l 'idtl
(Bie sod snld) i$0C-11VW 031d112133 2104 1d133321
(ap!S .aylo eaS)—0301AOUd 30V83AO3 30MnSNl ON "'d Sd
.................................... (pagnbae 001 0'4xe)_AN3AI130 1tl103dSP09 .
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MUNICIPALITY OF ANCHORAGE
IDepartment of Health and Environmental Protection
825 L Street, Anchorage, Alaska 99501
264-4720
uest for Approval of Individual Sewer and Water Facilities
Property Owner:
Mailing Address:
Name of Buyer:
Mailing Address:
Lending Institution: / i/L,S� IVcx',� /�
7%-/7iG
.Phone: '27;Z-44. z
Phone:
Mailing Address: , �€'�� dL ��0"'x A Phone:
sfis - 17�1(A .
Realtor/Agent :
Mailing Address: Phone:
5. Legal Description: 1.16 2 .3 d�Q«` �Gz Svgqb`Y �• «�`
Street Location: /0 ' <<� ✓J `- C7�fC Cxlp--
6. Single Family Residence: ( ) Number of Bedrooms:
11
Multiple Family Residence: (X) Number of Bedrooms:
7. Water Supply:_ *Individual Well (X) Public/Community System ( )
If Individual Well, well depth Fj
If Community System, name of system
8. Sewage Disposal System: *Ibn-site System ( ) Public System (X)
If On-site System, date of installation:
*NOTE: A well log is required on ALL wells drilled since 6/75.
**If on-site sewer system is over two(2) years old, an adequacy
.test is required by this department.
A fee of $25.00 must accompany each request before processing
can be initiated.
3/77
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