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PERMIT N0.
FIPF:'L I CHh,IT
L. OClaT ! ON
L. EGRL
]". STEWlaRT CONSTRUCTION
L9 [."ORR 2
8420 t4IL. LIt.,.IFt CIRCLE
LOT SIZE
]i: ]: _:.': - 86 S 4
200F'~0 SI..--.!LIFIRE FEET
MINIMUM [>IS'TRNCE BETWEEN la WELL BND laNY ON-SITE SEWlaGE DtSPOSF:IL S'¢S;TEM I'::;
:1.00 FEE]" FOR R PRI'¢FtTE WELL OR :1.50 "FO 200 FEET' FROM Fl PUBLIC NELl_ [:,EF'EN[:,IN.G
UF'ON THE T"r'PE OF PUBL. IC NELL.
MINiMLIM [:,ISTFINCE FF.'.OM R F'RI',,,'RTE 14ELL TO Ft PRIVFrTE SEWER LINE IS 25 FEET FIN[:,
TO la COMMUNIT'T' SEWER LINE IS 75 FEET.
WELL LOGS FIRE REtT.~UIRE[.', FIND MUST BE RETURNED TEl THE [:,EPFIRTMENI" WITHIN ~:0
OF' THE 1.4ELL COMPLETION.
OTHER RE6:!UIREMENTS Mla"r' FIPPL"r'. SPECIFICFITIONS FIND CONSTRUCTION [:'IFIGRFIMS FIRE
R',,,'FIILRBLE TO INSURE PROPER INSTRL. Lla]"ION.
F"EF.,:r-1 I T E ::-=:F' :I.: F-.' E_~=,: [2.,E-]E:E~"IE:EF: ]::IL.. ~,.. S-.~:'"-='; ::L
I C['-:RT I F'"? THlaT
±: I RM FRMILIFIR ~4ITH THE RE6!UIREMENTS FOR ON-SITE SEWERS; FINE:, WELL. S KC':; SET
FORTH E;'-r' THE MUN I C I PFIL I T"r' OF'
2: I WILt... INSTlaI. L 'THE S'T'STEZ~:C'RE:'laNCE WITH THE ,::,:,[:,ES;.
· FIF'~I",tT T. STEWlaF..T C:ClNS;TF..UE:T :[, fin
V4. 0
..... -:..:..,,-.h~,¢.,.~.~,r~s ce~ifi~:~b~r~seala~,~)~t~:~fl~-a[~fthe, vahdat~on date shown ~low, I ven~ that my
~ and ~pe ofstm~ure indi~t~ her~i?. I.fu~er .veri~ that bas~ on the information obtained from
~ :. ~ '~' ~-:~'.'~'.~. }':~'th~'M u n~o~i~i~':~Of ~h~O¢~ ~~'~'~' ~Y 'inv.t~flon and ln~P~ion, th~
. . . .~, . .,.,- ~r~ ~ ~ '~:-~ ..~, . : * ~.~<~X~,~..t~::..,-~,?.~,.. ~ ~:~:~. ~,.:;~. · . .~ ~ . ~ . .
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L-c:rr- Ot '[-~o.~-~, 5 [~, .~L 'z..- Parcel I.D. ~ ) ~ '- ,~' ~ ) - ,3' (~
A. Well Data
Well type ~'~,~
Log present(~)
Total depth
Sanitary seal~l) ,,~
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ? ~ ZZ- ~ / Driller
Cased to 1 o'=1 ' Casing height
Wires properly protected ~;Z:N)
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG
AT INSPECTION
g.p.m. ~', '7 '~' g.p.m.
Septic/holding tank on lot
Absorption field on lot
Public sewer main
SEPARATION DISTANCES FROM WELL TO:
Sewer service line -?..5'
WATER SAMPLE RESULTS:
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Coliform 0 Nitrate
Date of sample: ~ //'//g'~ / ,~
B. SEPTIC/HOLDING TANK DATA
Collected by:
Other bacteria
Date installed Tank size
Compartments
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
SEPARATION DISTANCES FR~DING TANK TO:
Well(s) on Iot....._..-..-'"'"'"'~ On adjacent lots
To pro~y line Absorption field
:,:~', ,~ ~ · ,, ,,, .
Surface wateddrainage
Foundation cleanout (Y/N) Ala ~e~)~
...-/~Pumper
Foundation
Water main/service line
72-026 (3/93)* Front
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DIST~,AN6~ROM LIFT STATION TO:
Well~'n lot On adjacent lots
Manufacturer
Manhole/Access (Y/N)
Surface water
D. ABSORPTION FIELD DATA
Date installed
Soil rating (GPD/Ft2)
Length Width Gravel thickness
Total absorption area
Cleanout present (Y/N)
Date of adequacy test
Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
System type
Total depth
De~ (Y/N) Bedrooms
..~er test
Jif yes, give date
SEPARATION DISTANCE FROM ABSOR~O:
Well on lot (~,,r'~djacent lots Property line
To building foundation J To existing or abandoned system on lot
On adjacent lots J Cutbank Water main/service line
c~SUdace er 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 [h~..~C~.e~ of this inspection.
signature
Engineer's Name //~')i)/'J~.,,~7-- C, ~'O~d,v'
Date / W S"'
HAA Fee $ ~ ~0, '-'"_ ..-.. Waiver Fee $
Date of Payment 2-~ "' ( ~, ' '-~ '~ Date of Payment
Receipt Number (~ ~ '" t~)0 ~ fl I Receipt Number
72-026 (3/93)* Back
COMMERCIAL TESTING ~ 9075941~1~1 N0.794 Q02
CT%E Ref.#
client Sample ID
Matrix
CT&E Environmental Services Inc,
I.~bo~ato~ Division ......................................
95.0659-1
,,, ~0~ s/~. Laboratory Analysis Report
WATER
Client Name S & $ BNGXNEERXNG WORK Order 12756
Ordered By R.J.S- Printed Date 02/2~/95 ~ 12:36
ProJec~ Name Collected Date 02/20/95 ~ 09~30
ProjeoC# Recel%,ed Date 02/20/9~ ~ 09:~5
PWSID UA
Techuicai DirectOr STBP;E~ C. ~DB
Sample Remarks: ROUTIN~ S;%MP~ COlLECTeD BY; MOB C.
QC A11 owabl · ~xt. A~la 1
ParameCer Reeult~ Qual Units Me=hod Limits Date Date Inlt
Nitrate-N 0.10 U m~/L EPA 3~3.2 x0. 02/20/9~ CMR
See Spe;ial In;truotione Above UA - U~avallable
** ~e Sample Re,%a=k~ ~bove NA = NOt
~= ~d~tec~ed, Reported Value is the praotical quantification limit, LT =Le;s Than
~= Se~onda%7 dilution. ~T = Greater Than
200 W. Potter Drive, ~chorege. AK ~518-1608 -- Tel: (907) 562.2343 Fex: (907) 561.5301
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA. FLORIDA, II.[,INOIS. MARYI ANn ~alC.l~4~l ~a~;n,;m ~=,~. ,c.ePw
APPLI/ ,NT FILLS OUT UPPER HA' ' ONLY
Address ~' '~,_,~(~ ~ ...... \,~ ~ (~ ~ ~ .,,, ~! C;~l Zip Code
Lending Institution Phone
Address Zip Code
Address
Zip
Code
Type of Residence
[~-Single Family
[] Multiple Family No. of Bedrooms
[] Other
Water Supply
(~'lndlvidual ATTACH WELL LOG. A wetl Icg is required for all wells drilled since June 1975.
[] Community For wells drilled prior to that date, give well depth (attach Icg if available).
[] Public Utility
Sewer Disposal
[] Individual Year Individual Installed:
{~ubllc Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
FieldN°tes: ~/~ 7~
J~ -- ~~'- MUNICIPALITY OF ANCHORAGE
~ j,~ (.,,, ,.._ ~ ENVIRONMENTAL PROTECTION
S~? 1 1983
(.~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72-023 (3/82)
' .-'~ ,~ ....... DATE RECEIVED
,4 ~:__ INSPECTION APPOINTMENTS
TIME ' TIME ' - TIME
DATE DATE DATE
~UNI01PALITY OF ANOHOHAGE DEPT.
~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~ONMENTAL
~_~' ~ 825 L Street- Anchorage, AI.ka 99501
~ ~/ ENVIRONMENTALSANITATION DIViSlON
ECEIVED
HEGU E~T FOH APPHOVAL OF INDIVIDUAL WATEH AND ~EWEH FAOI'LITi E~
DIH~OTION~: OomDlete nil part~ on pnge 1. Inoomplete teques~ will not be proceed, Please nllow ten (10) dnys forprooessing.
MAI LING ADDHE88 '
PHOPEHTY RESIDEN~ fif different fromnbove)- PHONE
3. LENDING INSTITUTION ' ' ' I PHONE
MAILING A~DHESS .....
4. REALTOR/AGENT _ ' ' I PHONE
s~..~ ~oc~ Z/'~ ~ ~ ,.t~.oous
6. TYPE OF RESIDENCE
~ One ~ Four ~ Other ,
~ ~ Two ~ Five
SINGLE
FAMILY
~ MULTIPLE FAMILY ~ Three ~ Six
7. WATER SUPPLY
INDIVIDUAL*
I [] COMMUNITY
! [] PUBLIC UTI LITY
l B.
SEWAGE DISPOSAL SYSTEM
I [] INDIVIDUAL/ON-SITE**
72-010 (Rev. 6/79)
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells dri/ed prior to tha/~d~lte, give well
depth (a_t~tach log !favaitable.) ~'~. ~,~ ~/p.
YEAR ON-SITE SYSTEM WAS INSTALLED.
~ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING. CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONL.Y
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
[] ONE
[] TWO
NUMBER OF BEDROOMS
[] THREE [] FIVE
[] FOUR [] SIX
[] OTHER
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] I NDIVI DUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank~or [] Holding Tank
Size: ...... I~ Tank is homemade
give dimensions:
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
TYPE OF TANK MANUFACTURER
MATERIAL
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
Septic/Holding Tank
IAbsorption Area [Sewer Line
iNearest Lot Line
5. COMMENTS
DATE
[~-'~APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVEDBYe(. ~
'/2-010 [Rev. 6/79)