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Home My WebLink AboutEARL RAY BLK 3 LT 28 ' 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 A [~NEW NAME MA LNG ADDRESS Well ~-- ~ -~- ~ I Absorptioq, area DISTANCE TO: m ~<~ Manufacturer ~~ ~ ~ Liq. capacitv in gallons ............ Inside length J ~ h HUIVIEIVIAL)E: NO. OP BE~O~MS Dwelling Materi~T'~__~ Width PE"% 'O 7 / 6 No, of ~...partments Liquid depth IWeU I Dwelling PERMIT NO, DISTANCE TO: ~/~/~ Manufacturer Material Liquid capacity in gallons DISTANCE TO: Well / (~ ~.~ Foundation / 2 ¢:=T-/Nearest lot ~ i~-~11- PER~_~O~ ~ ~/~ No. of linesI Length o~e¢ line ~ Total length~f li~ ¢~Tren~th Dista~ce~t~¢A~es ' ' ' grade ~ ~ Material beneath tile ~ Total effectjv~ ~o~tion area TOp of tile to finish 3 ~ ~ inches t W ~0 Length Wid' th Depth ] PERMIT NO-; Type of crib Crib diameter Crib depth Total effective absorption area DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO, DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIA~c~/~ ~0 ~ L.~ SOIL TEST RATINGi65 'NSTALLERA P'T~ ~ R EMAR KS r2-~,'~3 (Rev. 3/78) 1 t · 13~ . u'~-t t I hereby certify that ! haw . ,curveyed the following describe8 prope, r~y: J-ur 2"F~A/;~5~N~'r~%/'~¢' ~l,~k ~ , £,~ ~'t t~ ~' ~,~j, "' ~nchorage ~co~g Pmc~ ~sk~ ~d that the lmprovem~ ~tuated thereon ~ ~'~An the pmpamy lin~ ~d do uct overlap or encroach on lhe property 1)~ adjacent the:eto. ~zt no lmprevemen~ on pm~ ~n)' lying adjacent thereto encroach on ~e pmm~es quesDon ~d ~t there a~ no roadways, lL~es or a~ar vJsib~ ~sements an ~aid pro~ except '~s indicatcd h~mon. D~ted at Er, gle PAver, ~ka thi~ .... day of .4]:~/ / ~OBERT'C[ JOHNSON ~.~ 1" =~' Box ~, ~;le ~ver, Al~ka ~ [:,E.:PF~R'r??T [:~,EFL 'T'I'..I FIND IEN,, ] f-'~! ff.,h'E'.NTI::IL ~'T'Er_':T I ON ~ ::.=:,;ii.~i "L ;TF..:EET., FtNCH,::,F;~:~,~iE., ~::Jl':::. :~-~, ' ( 2 6 4-4 '7 2. 0 PERMIT NO.? ,.': 7807:;L6 > FIPF'LICFli'-~T M P.1 LI::IH 7G;0S~ E'.FIST :i.? FIg'ENUE LOC:I::IT I Ol'-~ FROI'.~"I-FIGE ROFI[) L.EEGRL LOT ;.2:::: E:LOCI< ii: EFIRI._ RF:I"r' E;,."'[) L. OT T'¢PE OF: SOIL. FtB'}.'!;ORBTIOI",! ':T,"?STEM ]S: TRENCH I'dF~XIi'dUbl NUMBER OF E,'E[':,ROOMS = '2.: SOIL RFIrT'ING ,::SQ FT,.."BR) .... ::L65 THE REQUIRED S.;IZE OF THE SO:IL. RBSORP'TION 2P-r'S"f'tEH IS: THE LENGTH D I MENS 1 O1'4 1:5 THE LENG"r'H ( I N FEET ) OF:' THE TRENCH OR [:,RR I t'*,11:::' ]:EL..I'.::,. THE DEPTH OF Fl TRENC':H OR PIT IS THE DIS;'T'FINC':E BETHEEN THE :!!!;LIF~'.F'FtC':E OF' TI-tIE GF.:CIUND FIND THE BOTTOM OF THE E::.::CR',,,'Fr'rION ,.'.'IN FEET). THE:RE IS NO SET !.4Ii}TH FOR 'T'RENC':HES;. THE GRFIVEL DEPTH :l:S THE MINIMUM DEF'TH OF:' GRR'v'EL BET'HEEN THE OUTF:'FIL. L.. PIPE FIN[:, THE BOTTOM OF THE EXCRYFITION ,:.'IN FEET). F'ERM I T RPPL I CRNT I-.IRS ]"HE RES;PONS I B I L I T'¢ TO I NFO)Ri"1 TH I S DEPFIFi'.TME':NT [:,UR I NG THIS I NSTFILL. FIT Z ON ~ I'.,ISPECT l' O1'.42; OF RN'.r' [,.IELL..S RD.]'FICENT TO "I"H ! S F'RCIF'ERT"r' FIN[::' THE NUf"tEJER OF RE$I[)ENCES THFtT THE I.,JEL. L. !-,JIL. L SERVE. E:RCKF::'I LL I NG OF:: RN'¢ '.=]"r':STEM 1.41 THOLJT F I NFIL INSPECT I ON RND FIPPROVFIL.. E:"r' 'T'H I S DEF:'F:IRTMENT I.'.IIL. L BE 5t..IBJEEC':T TO PROSECUTION. i'"IINIHUM DIS.;TRNCE E:ET!.,.IEEN R WELL FIN[) Rl",!'¢ ON-%ITE '}:i;EI.'.IRGE ::LOO F'EET FOR R PRIVRTE HEL. L...; OR t5¢3 TO 200 FEET FROM R PL.II~i!JLIC HELL DEPENDING UPON THE 'T"¢PE OF:' 1.4ELL. L ".: .":iS F:IRIE REC!UIRIE[:' FIN[:' MUST DE F;:.E:TJf4'I~IE[':' '1"O THE [:,IEF::'FIF~::TMEI",F[' WITHIN ]i:O [)l:::l'T':~i; OF:' ]"HE WELL COMF:'LETION. CrT'HER REQUIREMENTS MF:I"r' F1F:'F::'I...."r'. ':SF:'ECtFICRTIOI",IS l:::Ii"~g CONSTRU(;';TIOI",I DIFIGRFIM::":; FIRE I:1","I:::11 L.F:IBL. E TO I N':SURE PROPER I NSTRL. LFiT I ON. t CERTIF"r' 'T'HFIT 1: I RM FFIHIL. IF-]R I.,.II"I"H THE RE'.:.~_IREMENT!; I:-"OR OI'.,I.....S;ITt.E :SEI.,.IEI::.:S F:tI'.,I[:, I.,.IEL. L.'.!i!; l::l:i~; S1.:.':7't" FCIF..:TH B'T' THE MUNIC'IF'FiLIT"r' OF RNCHORRGE. 2: I WILL INSTFILL. THE 'SYSTEM tN F~CCORDFINCE P.II]"PI THE CODES. " " ...... .: .. ] EM Ml::l"r' F4:!!~:;CILI I RE Ei",II...I::IF~::I]iE]'"IEI'"IT ! I::' THE }:::: I I...IN[)ERE;TF:IND 'T'HFIT THE LN'--.::,I I E 'SEHER "'" "':: "': RESIf}ENCE I'..S REMOE:,ELE[:, TO INCLLIDE MORE THFIN }'.:: BEE:,ROOMS. ..................... . ....._...._ _ Steven'A, Johnson Box 76 Chugigk, Alaska 99567 Phone: 688-3085 Perfozmed for Martin W. Law X soils I~ X Percolation Test Date August 2, 1978 10 12 14 16 Legal Description Lot 28. B10ck3, Earl Ray Subdivision Test Pit Location See attached sheet ML GW GM w/GW O'-l' red sandy silt w/organics (ML) 275 ft2/bdrm 1'-2' red brown wellgraded sandy gravel (GW) 85 ft2/bdrm 2'-16' brown gray silty sandy gravel (GM with discontinuous leases of well graded sandy gravel (GW) perc test from 4' to 6' no water table encountered Total depth this test 14 feet AVEP~AGE ABSOLUTION AP~EA PJEQUIRED FROM SOILS LOG = ]80 ft.2/bdrm. DATE NET TIME (Min.) NET DROP (In.) PERC P~TE(Min/in) 8/]/78 30 8.5 3.5 30 6.5 4.4 30 5.25 5.6 30 4.0 7.5 30 3.0 10.0. 30 3.0 lO.O Percolation rate 10.0 Signed PERMIT NOo APPLICANT ARTHUR SRYLES LOCATION OLD GLEN HIGHWAY LEGAL L-28 B-~ EARL RAY SUB ~llJ[~ ! C I~IL ! TY 0~!~'~ DEPARTMENT HEALTH AND EN/IRONMENTAL .~TECTtON 825 ~L' STREET, ANCHORAGE, AK. 9~5~i 264-4720 ~,~EI b PERI~ZT ?80988 ) ST RT BOX 217 E.R. LOT SIZE 1OO00 SQUARE FEET MINIMUM DISTANCE BETWEEN A-WELL 8ND 8NY ON-SITE SEWAGE DISPOSAL SYSTEM IS i00 FEET FOR A PRIVATE WELL~ OR i50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. PERM I T EXP I RES DEl:EMBER ~l.. I CERTIFY THAT t: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. SIGNED:~~ ISSUED 8 ...... DATE - 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Corn plete legal description Location (site address or directions) Property. owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone w Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 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/gl) 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 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 inspectioh, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in affect on the date of this inspection. Name of Firm s~o~ ~ ~ w~._~,~r~'~ · Phon~ Date DHHS SIGNATURE __ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: Date The Municipality of Anchorage Depsrtment of Health anc~ 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 pumhaeers 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, 72-025 (Rev. 1/91} Be~k MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L-Z.~3, -~--~,.-I F--~ ~'u% Parcel I.D. ~S I- ll~- Z~ A. Well Data Well type -P~'~ Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Ok,- F'tL.£ Date completed ~-~_ 7g Driller Cased to 13%' Casing height "J' Wires properly protected (Y/N) ')" FROM WELL LOG AT INSPECTION I Z g.p.m. ~-',o g.p. Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot [I I ' Public sewer main ; On adjacent lots ; On adjacent lots Public sewer manho e/cleanout Petroleum tank q-I O0/ -+\00* Sewer service line WATER SAMPLE RESULTS: Coliform Date of sample: ~-~- Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size Foundation cleanout (Y/N) co o Compartments '7' Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Sudace water/drainage On adjacent lots Absorption field tOO Foundation 4' Water main/service line + 40 ' 72-026(3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Manufacturer Manhole/Access (Y/N) J "Pump on" level at "~vel at Cycle~ ste~eed Meets MOA electrical codes (Y/N) / h ~/-t- SEPARATION DISTANCE FROM LI~ STA~IO~TO~: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length Total absorption area Date of adequacy test Soil rating (GPD/FF) - System type Gravel thickness ~'/ Total depth it Cleanout present (Y/N) '"/ Depression over field (Y/N) Results (pass/fail) P'J~S~ for T~¢:~ I~" After test ['3" Width Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I I I On adjacent lots To building foundation 5" On adjacent lots + Surface water Curtain drain Property line To existing or abandoned system on lot Cutbank q- Ioo' Water main/service line Driveway, parking/vehicle storage area /VA 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. Signature Engineer's Name Date HO. 17;{2.2 .tur~ 2~., 19 HAA Fee $ / 7 Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number ..: ' · ";~:, :":'~.,~, ~;..~:~/J,', :DIVISION OF ENVIRONMENTAL SERVICES':~, ~ .... m,,,. ,M~ m, CERTIFICATE OE INSPECTION EOR ' ON-SITE SEWER.AND, WATER FACILITY,FOR SINGLE GENERAL INFo~MA~ION (MUst 6eC~mpl~ed Pri~r to ~L&~.,:L (a) :.Legal DesCdptio~ (includ'~' lot. block, subdi~i, sion,, section; township, range)_ Location (addresS%o,,[ d rections (b) Property owner Mailing Address' ' (c) Lending Institution Mailing AddresS' · ' Telephone'~:il~me) :" Business Telephone (d) RealEstate Company and Agent-" JACK ~HZTE COMPANY ATT~: Lo,C~z P&~&oA Address ~0928 Earl& River Road Eagl& Riv~r~ A~. 99577 (e) Iglail the HAAto the following address: (or che~i~ here I~cif hold for pici~-U:P;);. ~"~:'.. List contact person and day phone number below: .... ENGINEERING River, Alaska 2. TYPE OF RESIDENCE f; '~ ..... Single-Family ~x ~ Number of bedrooms '., 3. WATER SUPPLY Individual Well ~ Community Public [] .~"~ ~' ,L.~- '3 ~ - '~? ;* --L-L}!'~"~:{{ J ?.~'?~L~'I ~2P;~'~A' ~;~:. ~C,:V :,.. f~ ?:. :_4 .. ~: Note';' f'b0~m~'fl'ii~:'~ sgste~ 're'f st h~qb-;writte~ Cohfi'~',atiOh~[O~ th~State,. _,.~:~ -. . , ,. ~ ,-,,:;~ ,;: ~-: ..,': ,._~ ,.,: .;:;~ ~;, ,~k..,;, .Li6.~-.p% ~,~:~%~:t=~:~'%~*~9.%~,~i~,~ ~,~,,~ 72~25 (Rev. 7/88) Page~l 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as ortho validation date shown below, I verify that my investigation of this Health Authority Appi'ova/shows.that',the onLsite.water supply,and/or .wastewater disposal system is safe, functiona .and adequate for the number of bedroom$"ahd 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 dispos~.l System *is in compliance with all Municipal and State codes, ordinances, and regulatiOns in' effect on the date of this inspection,, Name of Firms ;_. $ ;h;c. INEERING '~ 17034 Eagle River Loop Road No. Address E=g!- g;ver: Alaska 99577 Date Telephone 6. DHHS APPROVAL Approved for Approved ~ '", Disapproved Terms of'Con~l'itional ApProval '-~'~ ...... ~ :~ :i ' - .~:.::~ ...... :'r ;1 Conditional .? -2 7-?/ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 re? ponsible 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 Lega Description: A. WELL DATA Well Classification "~--r~. ~?,~ [~,'~ Well Log Present(~N) V Date Completed Total Depth ~.'~P~ ' Cased to '~r~~' Depth of Grouting Static Water Level Casing Height Above Ground 17., Electrical Wiring in Conduit ~N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sam pie Collected by Water Sam pie Test Results Pump Set At Sanitary Seal on Casing(~i~)/N) '~/~ Depression Around Wellhead (Y~) If A, B, C, D.E.C. Approved (Y/N) YielC ~',z~ ~'~p ; On Adjoining Lots I ~c:~ ; On Adjoi'ning Lots To Nearest Public Sewer Cleanout/Manhole ~-.d-~ ¢~-,,_~r,&c_._~,_.iz~,-5,1.~ ;Date ~ - ~¢t ~ Comments B. SEPTIC/HOLDING TANK DATA Date Installed I~- ~-'7~ Size ~.~"~ Standpipes ~N) '",J Air-tight Caps(~TN) Depression over Tank (Y~ r-~ Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) "'~J~'- No. of Compartments 'Z_ Foundation Cleanout ~/N) Date Last Pumped ~' \~ -% \ ; for ~ Temporary Holding Tank Permit IY/N) ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-,Supply Well '~,~> ~" To .Property Line ~D' ~ To Water Main/Service Line ~-~' '~ To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation To Disposal Field 72-025 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed \\- \'~,' -"] Width of Field ~--~L~" Square Feet of Absortion Area Depression over Field (Y/~ Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (~N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation \ _¢2'~~- Lot ~'-~'//~r To Water Main/Service Line ~:,~ '~' To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line \ To Existing or Abandoned System on ; On Adjoining Lots ~ To Cutback (if present) D. LIFT STATION Date Installed Dimensions Manhole/Access (Y/N) "Pump On" Level a~'t----~. ~ "Pump Off" Level at High Water Alarm Level at Tested for ~ ~ Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/~--'""'"'~"~ ~ . Comments ~' **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. $ & S ENGINEEb~tNG 17034 F. ag;,= R;,,,~' Lo,~p ~,~,~J No. 204 [~aqle River~ Alaska ~9577 Signed Company Date .'~ MOA No. Receipt NO. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORY A [IIVISION OF COMMERCIAL TeSTINg; & ENGIN~E__RIN~__,, . ..... ,,,,..., ,,. //~.~/¢ illo~eble NIT~ATI-# 17034 Eagle River Loop Road Eagle River, Alaska 99577 ROBERTA, SHAFER ClVILENGINEER 694-2979 CaR Occur. Comments: "v~--- ~..o~oC.~.~ ~-. C~ ~pr~ FlowlsnotGuiranteed Subsequent Variations CLOCK ELAPSED TIME SINCE DEPTH TO DRAWDOWN/ PUMPING PUMPING STARTED/ WATER, FT. RECOVERY RATE~ GPM REMARKS TIME STOPPED, MIN. ~-',co C:) '~ 0 ~:~ (swl) 0 0 8tart ~::::~-c, ~} c~ ~,,..~ 10 3~ .. ~p ,,. 45 ', ~ ~.'.~ o ~o ~'~' ~' ~.~" 55 ~0 (1 hour) 90 ~'. o ~ ~012 hours~ ~' ~' ~,o" ~.,~ 150 & ~ ~ ' ~' ~. ~ ~ 1~ {3 hours) ; ~,,~ ' 210 ~ ~., ~' ~, o ~ .~%~ RECOVERY ~ ,35 PROJECT: ~'~,ci~-- ~,~y~\~'~,, ~,~, - ~o~ DATEOFTEST:~'~-~ LOCATIONOFWELL(LeGalDescrlptlon): ~ ~ ~ ~ ~ ~ WELLOEPTH: ~' FT. CASING: ~ O ~ ~ FT. SCREEN: DATE DRILLING COMPLETED: ~-~ DRILLER; ~ ~[~ STATIC WATER LEVEL ~op of Casing): ~ ' FT. .DATE: ~ - ~ insPector Inspector Inspector Comments ~'~~ Conditional Approval Date Permit No. Septic Tank Size / } { - ~ ~7 Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank Buyer Address Type f~g~.l~nce [] Multiple Family No. of Bedrooms [] Other WateL,~pply [~-Individual ATTACH WELL LOG. A well log is required for ail wells drilled since June [] Community 1975. For wells drilled prior to that date,* give well depth (attach log if [] Public Utility available.) Sewatge~J~sposal I~lndividual Year Individual Installed: / [] Public Utility When Connected to Public Utility:. [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. ~ DEPARTMENT O~ .EAL~. · EN~,"ONME"TAL P.OTE~ ~ ' · ~ ' I 825 L Street - Anchorage, Alaska 99501 "ENVmRON~ENTAL ENGmNEERmNG DavmsmoN APR 2 6 t979 Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES P P E~ PHONE PROPERTY RESIDENT (If different from abo ~ ~ MAILING ADD~ES8 3, LENDING INSTITUTION ~ PHONE ~ MAILING ADD~ ESS 4. REALTOr/AGENT m PHONE MAILING 6. I'YPE OF RESIDENCE NUMBER OF BEDROOMS [] One [] Four [] Other~ EEt/SI NG LE FAMILY [] Two [] Five [] MULTIPLE FAMILY [~Three [] Six 7. WATER SUPPLY [~'~N DI¥1 DUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well Io~ is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ~ II~r~'"~'"DIVIDUAL/ON-SITE** **If individual/on-site, give installation date ~ · If system ~s over two (2) years old an adequacy test ~s required [] PUBLIC UTI LITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72.o,o,3,78, o k<. THIS SIDE FOR OFFICIAL USE ONLY DATE R ECEIVEL) INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE i INSPECTOR INSPECTOR INSPI:CTOR DIRECTIONS: 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 [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER [~]Septic Tank or I~] Holding Tank Size: r~ ~D~O IfTank ishomemade i SOiLS RATiNG give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line I Nearest Lot Line I WELL TO: ] ~C~ Absorption Area to nearest Lot Line 5. COMMENTS [] APPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) IZ~~ DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev. 3/78)