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HomeMy WebLinkAboutELDON BLK 2 LT 14 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES ALBERT P. KNOEDLER FROM~ SEPTIC ABSORPTION WELL Address TANK FIELD Phone(s} . LEGAL DESCRIPTION Lot J Block Subdivision Town!hip,~Rang], Secti~ ~'~ FOUNOATION AS-BUILT DIAGRAM (Show location of well, septic system, properly lines, foundation, driveway, water bodies, etc.) ~ ~ HOLDING Manufacturer ~~~l~s. aaterial No, of CompaKments TYPE OF SYSTEM ~ ~oT ~ ~ TRENCH ~ BED ~ W. DRAIN ~ OTHER Depth to pip. om frottom from Totai depth from original grade gra~ FT FT original Fill added above original~ Gravel depth beneath pipe FT FT Gravel length ~ Gravel width F7 ~ FT .., SQ FT F1 Number of lines Soil rating Pip SQ FT Date Installed Installer ~PRIVATE ~ OTHER (Identify) Classification (A,8,C) Total Depth 1cased t~. REMARKS: I Date: ,~~ t ~ ce.fly that this inspe~ion was peHormed according ,o all Health Depa.ment Approval: ~ 72-013 (3/85) WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys Drilling Permit No. OCATION OF WELL (Plenle complete either lo, lb or lc.) A.D.L. No. Io.llso,augh Subdivl,lon Lot Slack 'b.II '/4qtr,. Sectle, No. Tow,ehlpNE~ Re,ge ED Merldln/I Street AddreSl and Aria of Well Locution 2. WELL LOG Flat Below 4. WELL DEPTH: (fln.l) 5. DATE OF COMPLETION Mottrlal Typa Top Bottom '-~ / I - ~ ~ ~ ~ ~1 ~ ~ ".CASING: ~ Threoded ~ WIIdld ~- ~1 ~' 4~1 ~ ,,,-. ~ ,.. ,o~,,. ~.,,h w.,,,, ,../,, ~ dlom..~ln. Io.~ ff. Depth Sflckup~ ff. 9. FINISH OF WELL: Type: ~ ~ Dlometer: I Slot/Mllh Size: Length: Set between ft. end ft. Backfilling Gravel pack ,o. ,~m,c W~T~, ~w~:~,,. / / II. PUMPING LEVEL below land ~urfa=l and YIELD ~ft. offer .~hr~. pumping .. g.p.m. MUNiCIpAU~ ~ A~E ~,SROUTmS WeU Srouted: UEFI, UF ng~blrl a Material: ~ Neat Cement ~ Other: E~a~MENTAL PROTE~I ~ 16. WATER WELL CONTRACTOR'S CERTIFICATION: 15. Water Temperature o ~ F D C This well wee drilled under my jurisdiction and this report le true to the beet of my knowledge and belief; Regietered Bueine~,e-'l~/ame Contract License Number ' A,;'t horlzed Repreeentotlve MunicipalitYof Anchorage P.O. BOX 196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES May 20, 1987 Albert P. Knoedler PO Box 110577 Anchorage, Alaska 99511 Subject: Lot 14 Block 2 Eldon Subdivision On-site Well Permit # 860132 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of May 19, 1987. Your permit expired on the date of issue basis by authority of Municipal Ordinance existing at that time. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. The new permit will come under the calendar expiration date as per the Wastewater Ordinance (effective May 20, 1986). If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system the original as-built inspection report (three-part form) must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 343-4744. Sin~ly, .W. Robinson Program Manager On-site Services RWR/ljw enc: copy of permit DIEPAR'T'MEI',H" OF HEAI...."I"H AND IEI',IVIROt',IMIEIq'T'AL. F'RO'I"E~'TIOI',I 8,?.5 L. S]"F;~EE]", ANCHORAGIE~ Al< 9950 ,'.::'~ 64 '"" 4 '72 () PJiiiJF~i"l ]] J' hli:): 86 () :I. :32. 05 / .1.9/86 A F::' F::' L ]: C A N T: {,.~DI,)l d,,..,..~,.,. CON"FAC'T' PH[INE: AL..BEF~'I" P. I<NOEDLER F:'.O,, BO,X 11057'7 ANCHORAGI-~i:, AK 995 :t, :[ LO'T' SIZE: SUBDIVISIC}N: ELDON ,~[:.(.., F i UI I: 19 TOWIxlSH I F:' 1 1()0C~ (SQ,, F'T. OR AC;RES) LCI'T': 14 RAIxlGE: 3W I ~:::et't:Lfy 'Lhat: 1., :[ am Cam:[liar' wi'Lb the pequir'ements £cw on-site sewers and we].],s as set For"Lh b'y 'Lhe MLu"~icipa],ity oF Anchor'age (MOA) arid the State oF Alaska. 2. I will instal, l. 'Lhe system J,n ac:c:c)r'dar~c:e with all M[)A cc)des arid r'egu].at:Lc)ns, ar'id J.n compliar'ice wit. h 'Ll"ie design cr'iteP:i.a oF this per'mit,, :3. I w:i.],l adh6:,r'e to all MOA and StaCe cJF Alaska r'equ:Lr'ements F(::m the se'L bacl< cJJ. s'Larlc::e~i~ ~'r'om any existing well, wastewateP disposal, system c:)r' pub].ic sewer'.age C]~y~E'[,(~.~/'li (21] th:Ls t~p al"ly adjacent oP near'by 1Q'L. :~ ]. ~, 141 .D AF::'PI.,.:[CANI'= .:.~1.,.[.1:.1¥t' F'. I<NOEDL, ER D A T'E: unicip h y of P.O. B 196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNOWLE$, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES June 23, 1986 Albert P. Knoedler P.O. Box 110577 Anchorage, Alaska 99511 Subject: Lot 14 BLock 2 Eldon Subdivision On-site Well Permit #860132 - Issued May 19, 1986 On May 20, 1986, The Anchorage Assembly approved a new ordinance regulating ou-site wastewater disposal systems (septic systems). Ail septic systems constructed after the effective date of this ordinance are subject to the provisions of this ordinance. Our records show that you currently hold a permit for the installation of a septic system. We strongly urge that you contact this office prior to constructing your system. Any changes in tile code that could impact the construction requirements of your septic system will be identified and brought to your attention. Please contact the Environmental Services Division at 264-4720. Thank you for your cooperation. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/SSM/ljw 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 NAME i MAI LING AI~R ESS LEGAL 9ES~RIP~ION LOCATION ~ O ~ DISTANCE TO:WellAbsorption area ~ Z I Manufacturer  Liq. capacity in gallons : Inside length IF HOMEMADE ~ -- ~ DISTANCE TO' I Well .~ ~ I ' I ~ Manufacturer ~~ ~ O J J Well ~ = I DISTANCE TO: I ~ · ~ N~ L~ ~ ~h ]i~ ~ . . . ~ I~ ~th ~ ~ I Type of crib Crib diameter Dwelling Material Width Dwelling j(..~ / PHONE ~pGWRAD E Foundation Depth Crib depth Driller Sewer line Nearest lot line NO. OF BEL~OOMS PERMIT NO. No. of compartments Liquid depth ~[.~_ PERMIT NO. Total length of lines Trench width Distance between lines inches Material beneath tile Total effective absorption area inches PERMIT NO. Total effective absorption area Building foundation Nearest lot line Distance to lot line Septic tank IPERMITNO, Absorption area(s) OTHER PIPE MATERIALS C/~T SOl L TEST RATING INSTALLER REMARKS APPROV~~ D~ATE LEGAL PERMIT NO. t.ILINIC' >RLIT¥ OF Rr-4C, iDRRGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 'Lt STREET, ANCHORAGE, AK. 99501 2~4-4720 ON--SITE ( 800022 > APPLICANT LOCATION LEGAL JONAS ARNBRISTER LT 14 BLK. 2 ELDON 3400 MTN. VIEW DR. LOT SIZE c I TYPE OF _.CIL ABSORPTION SYSTEM IS: PIT MRXIMLIM NUMBER OF BEDROOMS SOIL RATING (SQ FT?BR)= 'THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: DEF'TH= LENGTH= GRR'-.-'EL DEPTH= 15000 SQUARE FEET THE LENGTH DIMENSION IS THE LENGTH (IN FEET> OF EACH SIDE FOR R SEEPAGE:PIT. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION <IN FEET>. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET>. F~EL~LIIREC, /-Z/O/J/~C.-- TANK SIZE= 2888 GALLONS !~ERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE ENSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE '~UMBER OF RESIDENCES THAT THE WELL WILL SERVE. OW~ (/~ I NSPEL-':T I Or-4S I---~RE REQU I RED iI~CKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION 8ND HPPROVAL BY THIS )EPARTMENT WILL BE SUBJECT TO PROSECUTION. ,IlNIMUM DISTRNCE BETWEEN A NELL AND RNY ON-SITE SEWAGE DISPOSAL SYSTEM IS :L00 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING _~PON THE TYPE OF PUBLIC WELL 3THER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS RRE 'iVAILRBLE TO INSURE PROPER INSTALLRTION. : PERP1 I T EXP I RES ~"~ ~/~ /! 1~.~80 '/y/ ~ George M. Sullivan Mayor ANCHr'~AGE WATE!:~ & SEWER 0~-[LITIES 3000 Arctic: Boulevard Anchorage1 Alaska 99503 (907) 277-7622 Music ~^u'~ o~ DEPT- OF 1.2AL'[H & FEB 9" '~980 Owned by the MLmicip~hty o! Anchorage February 25, 1980 Jonas Arnbrister J. A. Contractors 3400 Mountain View ])rive Anchorage, Alaska 99501 Reference: Eldon Subdivision Block 2, Lot 14 Dear Mr. Arnbrister, This is confirmation that sewer service is available to the above property, located on Jack Street. aic%ncerely' ie M. Mace Customer Service Supervisor Anchorage Water & Sewer Utilities cc: Les Buccholz - HEP Bob Daniels - Project Control Municipality Anchorage DEPARTMENT OF HEALTH & HUMAN S Albert P. Knoedler PO Box 110577 Anchorage, Alaska P.O. , X 196650 99511 Subject: T,ot 14 ]Block 2 Eldon Subd±v±s&on On-s±te Well Perm±t #860133 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December .31, 1986. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. In addition to the expiration of the permit, the fees for the subject permit were not paid nor the permit signed by the applicant. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as-built inspection report(three part form) must be sent to this office for review and approval, and for documentation. The fees for the permit will need to be paid and the permit signed by the applicant if any or part of the installation have been installed. If there are any further questions, please call this office at 264-4744. R.W. Robinson ~ Program Manager On-site Services RWR/ljw enc: copy of permit DEF:'ARTMENT OF HEAL.'TH AND I.EI%IVIRONMENTAL. FtROTEC'T'ION ~)~'m ~]f~ ~+II !i~'I"REIi:.:.'T~ AtxtCHOI:RK.~tE, ~1'::: 99501 264-.4'720 A F::' F::' I.... I C; A N f': A D D R E S S: C E) N T A C'T' I:::'H 0 N E: [..EGAI_ :C)E:E:~CF~ I F::': L 0 T S I Z IE: LO'T LOC(.YI" I ON: AL..BEF?T F:' KI~OEDL. IER P [) DC:IX 110,577 AIgCHORAGE~ AK 99511 349-6953 LO'T': ]. 4 RANGE: 3W B L OC;I<: ,2 1. I am f'am:i.l:i, ar' u,.~:i.t.h t. he i-equil-ement, s fop on-.s:i, te sewer's and wells as set fopt. h by the Munic:ipalit. y oF Ancho~age (MOA) and t. he Stat. e oF Alaska. 2.,, I will ir'H~H:.a].l t. he syst. em in acc:or'dar~c:e wit. h all MOA codes and r'egulat.:i, cu"~s, and ir'l cc~mp].:i, ance wi'l:.l"~ t. he design cr'iter'ia c:)f' this per. mit., :3. I will. adher'e t.c) all MOA and St.a'Le c)f' Alaska ?,equir'emen'Ls f'c)r' the set. bacl.:: d is'Lances f r'om any ex :i.s'L il']g wel t, was'l:.eA~at, er' disposal, syst. em or' pul::, 1 :i.c sewer'age syst. effl or'~ 'Lhis c)r' any adjf~tE:er~t OP near'by lot,, ~-' WATEP WELL LOG '~ FOSS DRILLING ASSOCIATED 909 CHUGACH DR. #37 ANCHORAGE, ALASKA 99503 WELL OWNER Albert Knoedler USE OF WELL WELL LOCATION Lot 14 Block 2 Elson Subdivision Domestic SIZE OF CASING 6" STATIC WATER LEVEL REMARKS DEPTH OF HOLE 48 8 FT. Go Po M. FT. CASED TO 48 FT. 2 WITH 38 FT. OF DRAWDOWNo DATE COMPLETED 10/15/79 PUMP TO BE SET AT 47' 0 to 5 Alluvium; brown color and soft 5 to 13 Alluvium; grey color, medium hardness 13 to 17 17 to 18 18 to 28 28 to 47 Sand and Gravel; grey colors medium hardness~, with water Sand and Gravel; brown color, medium hardness~ with water Alluvium; grey color~ medium hardness Till; blue-grey color and hard 47 to 48 Sand and Gravel; blue-grey color, with water to to to to to to to to MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROT'3CTION NOV 8 1979 I~I,,~,L I ¥ 'to ::~. ~:r~; f;~~ 'l~ ~ ;:!'.11!:.!1:!:.! ~;::E:iili!!i"t'' ~::'1:;i:O1''1 I:::! F'l...IEi;Liii(i:: ~'"IEL'[-- DE!iI:::'END:[NE!i LE::'EIN I'.I[EL.L. I...OEiE}: F:!I:;;:IE F;%(i:E..IiI:REZ:' I::![",l[;:' I','[UE;'r' IE:E ~:~:IET'URNE%, "FEi 'THE: OF:' THE; NE;L[... E:OHF'L.E"r']:ON. 0 T'HE:I::;: I:;;:IEE'¢J :[ F?.E:HE:I'.,IT:~:; !"'I]:::¢'/ i:::II:::'F:'L."r'. :~:F'E:C :[ I:::' :[ E:FI'F ): 01",1~; FIND I:::l',?i:::~;[L~f::~l~;l.E!; "r'E;I ;l.i",!:~;IJl::?.E~; I:::'I:('.OF:'E;i:;r F'OI:;i:'T'!"I E',? T'HE I"IUN ;[ (:;: ;I; F:'F:II.... ;[ T"/ 0t:::' 2: ;I; 14 :f I..L. ;I; N?FFE..L. 'r'HE 2;'T':ii?f'E;I"t ;I; N F:t(;:(];:(;;IF;;:[]:,F:IJ'.,I(;]:J!i!; I.,.! :[ TH THE; / PILIN l~'I PaL I T~ ,3F FI~.~L-:H,:,E:R,_~E . DEPARTI' ~tT OF HEALTH AND ENVIF:ONM' fAL PROTECTION x~.~, 9~[ 8k5 'L' STREET, 8NCH~R~GE.,~ ~K. 995C~1 C 0 ~ WELl .~ R~-4D t~f~--~:~. I TE ~:EFJER F'E~PII T PERMIT N~ / LOC~T I0N ~i~ LEGRL l~ff <5'~c~'~'~C~' , LOT SIZE ,I ~C0 SQLRRE FEE TYPE OF ~OIL RBSORBTION SYSTEM MRXIMLIM NUMBER OF BEDR00I'1S = .} SOIL RRTIN6 (SQ FT,/BR>= THE REQUIRED SIZE OF THE SOIL 8BSORPTIOr. I q, ,c_ ,_,TEM I~"=,. r)EF'TH-- LE~-I;3TH= 13 F-: F! '...' E L [)EF'TH= THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIEED. THE DEPTH OF R TRENCH OR PIT I:5 THE DISTRNC:E BETWEEN THE SURFRF:E OF THE GROUHD RND THE BOTTOM OF THE E)<CF~VFtTION <IN FEET), THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRF¢,,'EL E:ETL4EEN THE OLITFRLL PIPE RND THE BOTTOM OF THE E,'<CF~VRTIAN (IN FEET). F.:ELi!LI I RFC., ~.-.~EF'T I C: TRI'-,II-( '---; I ZE.-= F'ERHIT FtPF'LICRNT HR=tS THE RESF'ONSIBILIT"r' TO INFORM THIS C'EF'RRTMENT [>URING THE INSTF~LLRTION INSPECTIONS OF RN"r' HELLS R[:'JRC:EHT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. TI---IL-i ,-'. 2 .'-, I I'-,I'-----,PEC T I C'~-45 RF.'E RE~;!LI I F.: E C.., E:F~CKFILLING OF RNM SYSTEM WITHOUT FINF~L INSPECTIOt'I ~ND RF'PROVRL E',Y THIS DEPF~RTMENT WILE BE SUBJECT TO PRASECUTION. MINIMUM DISTRNCE BETWEEN R WELL AND RNY ON-SITE SEWAGE [:'ISPOSRL SYSTEM IS IE~O FEET FOR ~ PRIVRTE NELL,: OR 150 TO 200 FEET FROM ~ PUBLIC WELL DEPENDING UF'ON THE TYPE OF PUBLIC HELL WELL LOGS RRE REQUIRED RNC, MIJST BE RETURNED TO THE [:,EF'RRT;,1ENT WITHIN ~E~ DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS f,IRY RF'F'LV. SPECIFICRTIONS RND CONSTRUCTION DIRGRRr,IS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. F'ERP1 I T EXF' I F-:ES C.,EL--:Ei'.IE:EF.: _----':1.. l--a. 79 I CERTIF'¢ THh]T l: I RM FRMILIBR WITH THE REQUIREMENTS FOR ON-SITE SEWERS F~ND HELLS RS SET FORTH BY THE MUNICIP~LITY OF RNCHORRGE. 2: I WILL INSTRLL THE SYSTEM IH BCCORDh]NE:E WITH THE C.O[:,ES. }: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MA'¢ REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE r,10RE THF~N ::: BEDROOMS. Applicant Box 4-1088 On January 15, 1976, you t~ok out a vel1 petit from contact you by tele~on~ and has received no info=ma- ~ton f=omyou In the ~orm of a w®ll log to tn~ttoate the for a one (l) ~ear ~i~, m~im~ ~is ~i2 ~v~lid. Un~tl fur~r ~o~io~ ia ~e~eAved fr~Mou or ~e ~11 4rt11~, ~e well, ~f~ill~, can not ~ agproved, offioe at 279-2511, or oome into our o£fi~es at ~2~ L S~ree~ Four~hFloorWesto D, EF'RFJTMENT OF HERLTH RN[) ENVIRONMENTAL P~'.OTECTION HNL. HO~'.HME., 3:5:3:0 C STREET, ...... ' ...... ~'~P;"~ 274.-456~. PERM I T NO. ,. .......... ,. ~,r~kl~ ~ ., ........... , ....... RLE,.ERT kNU. LDLEF~. BO,,, 4.-t8,=-_ - '-~ EOC:RT I ON ' 3RCK LE~RL L&4 B2 ELE:,ON .~UB[ -' LOT SI~:E tO:3OO ~' r~-- MINIMUM DISTRNCE FROM WELL TO RN'¢ SERTIC ~RNK, RRC. KR~ PLRNT OR SOIL RBSORRTION ~.O~z FT FuR R PUBLIC WELL. =,~STEM IS t80 FT FOR R PRIVRTEWELL RND WELL Lr36s MUST BE RETJRNE[:, TO THE DEPRRTMENT WITHIN ~8 DR'CS OF THE WELL COMPLET I ON. E I '= I-' -I ' "' ~ ' "- 5PEL. IFICR[ILN=, RND ...3N_TR__.TI~N [.Ih]L~RRIfl=, RRE fi'v'RILRBLE TO INSURE PROPER I NSTRLLRT I ON. I E:ERTIF"r' THRT I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE _,EWER=, fiND WELLS RS SETFORTH B'¢ THE rlUNIL. IFRLI]¢ OF RNCHORRGE RND WILL INSTRLL IN RCCORDRN~]E WITH THE CODE. ~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES H87-0572 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 14 Block 2 Eldon Subdivision 12/19/87 Location (address or directions) 711 Jack Street, Anchorage, Alaska 99511 (b) Property Owner Albert. Knoedler 'Telephone: Home Business Mailing Address 711 Jack Street, Anchoraqe, Alaska 99511 (c) Lending InstitutionCor~mon Wealth Mortqaqe Telephone 562-6477 Mailing Address 3601 C Street~ Anchorage, Alaska attn. Mike Fomelle (d) Real Estate Company andA§ent Fortune Properties attn. Dick Decker Address 3000 A Street Anchoraqe, Alaska 99503 Telephone 5 6 2- 7 6 5 3 (e) Mail the HAA to the followine address: or: Check here 1~. if hold for pick up. List contact person and day phone number below. Dotten Drillinq Earl Dotten 344-1952 TYPE OF RESIDENCE Single-Family [~ Number of Bedrooms 3 WATER SUPPLY 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. SEWAGE DISPOSAL Onsite [] Public i~l 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 I of 2 72-025 IRev 8/86) Front ')~JOM s,Jeeu!Sue leUO!SSeioJd aq~ u! suo!ss!uuo Jo SJOJJG JOJ @lq!suodseJ iou s! eSeJoqouv ,to Xl!IBd!o!unlAI @ql 'penss! s! e),eog!peo B eJojeq mep eZ/~lBUB 4o suo!~o@dsu! lonpuoo ~.ou op SHHQ j.o see,~OldUJ~] 'siue~ueJ!nbeJ elBls pub IBJepej u!elJeo ,~Js!ms m, JepJo u! suo!lnl!~su! 5u!puel J!eql pub seauoq 1o sJeseqoJnd oh Xse),Jnoo e se Jeeu!Sue ieuo!ssejoJd luepuedepu! ue Xq eAoqe ~; qdeJ§e~ed U! UeA!5 suo!m),ueseJdeJ CAoJddV ~Moqlnv q),lBeH senss! (SHHa) seo!AJeS uBu~nH pub q~,lBeH NOI/n¥3 886I '05 ~un£ Aq LS-IE-EI ,{i;[edozd pauopueq~ sT IIe~ PIO I;e^oJddV IBUO!l!puoo ;o X IBUO!I!PU°O po^oJddes!c] poAoJddV '9 lees s.~aau!6u~ L86I ~6I ~@qu~@oeO mBO ~0§66 ~Ms~I~f 'eB~;~oqouv 6955 q~E ~ 00E S~O~AIeS UO~q~B~S~AUI ssaJppv · uo~loedsu~ s~41 ;o amp eM1 uo 19e~e u~ suo~l~ln~eJ pu~ 'seou~u~pJo 'sepo3 e~E1S pu~ l~d~mun~ H~ q3~ eou~Hd~oo u~ s~ ~els~s i~sods~p Jem~els~ Jo/pu~ ~lddns JG~E~ el~S-UO eql 'uo~33edsu~ pu~ UO~IB~lSeAU~ ~ ~OJ~ pu~ Selg e~E~oqou~ ~o ~l~l~d~o~un~ eql ~oJj pem~lqo uo~lB~JOjU~ eql uo pes~q mql ~lUeA Jeq~ni I 'u~eJeq pel~o~pu~ eJnlonJls ~o ed~l pub s~oo~peq jo Jeq~nu eql Jot emnbep~ pu~ I~uo~3unt 'e~s m ~els~s I~SOds~p Jel~elsE~ Jo/puB ~ddns Je3B~ el~s-uo eq~ 1Bql s~oqs ~BAoJdd~ ~lpoqln~ qll~eH mqliO uo~l~lSeAU~ ~ 1~q3 ~peA I '~oleq u~oqs el~p UO~l~P~l~A eql lo sg pu~ OleJeq pexgl~ I~es ~ ~q pe~j~eo sV NOI~OdNI QN~ ~Z~Q 'HOB~S ~31d 'S~S~ 'SNOI~O~dSNI 9NIQIAOBd ~1~ 9NI~NIgN~ Mt;NiciPALi~¥ OF ANCHORAGE EN,,/19.ONMF..NTAL SE~',/ICr:-S D~V~StO~ WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: Well Classification ~ i .DcE-~J .'~'~ AL. If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) J~/~ Date Completed (~ ' i(~ ' ES~ Yield Total Depth <~'~ ~ Cased to ~'~' ! Static Water Level '~'-'~- ' Casing Height Above Ground ~,.O t, Electrical Wiring in Conduit (Y/N) Separation Distances from Well: Depth of Grouting Pump Set At ~ Sanitary Seal on Casing (Y/N) Y Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot k) /~/~ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results ; On Adjoining Lots .Id//3, ; On Adjoining Lots ,k) .//~ To Nearest Public Sewer To Nearest Sewer Service Line on Lot ,_,%..~ I EE//~i~--L- O©TT-~-~ ;Date I1~_! 1~'-!~"7 Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course Size No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72~026 IRev 8/86t Front C. ABSORPTION FIELD DATA 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 Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test 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 Cutbank (if present) D. LIFT STATION Date installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify"¢~"~'~ cl~d~rifie¢~r conformed to all ~OA/and NAA guidelines Date of Payment ,//~.--~.~L./ __.¢6-' 7 Amount: $ // ¢) g ~ <~ Page 2 of 2 72-026 fRev 8/86) Back in effect on the date of this inspection. CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ANALYSIS RI~PORT BY SAMPLI~ Client PO# : V~BAL Req ~: Client Smpl ID: LOT 14 BLK 2 JACK STREET S/D Sample Rec'd : DEC 14 87 Ordered By : EARL Send Report~ To: DOTTEN DRILLING CO. Work Order No. : 4352 Client Account : DOTTENTA Date Report Printed: DEC 16 87 8 13:42 Released By : 2,~k~,~,/ Reports Address #2 8537 HARTZELL RD. ANCHORAGE, AK. 99507 Special COLLECTED 12-14-87 BY J.D. Instruct: Chemlab Ref ~: 8605 Lab S~pI ID: 1 Matrix: Water Allowable Parameter Tested Result/Units Method Limits NITRATE-N ND(0.10) mg/l 10 Sample ROUTINE SAMPLE Remarks: ANALYSIS COMPLETED: 12-16-87 1 Tests Performed * See ~eclal Instructions Above ~ None Detected ** See 8~le Remarks ~ow NA= Not ~al~zed LT=Le~ ~an, ~=Greater ~an DATE RECEIVED INSPECTION APPOINTMENTS ,TIME,, TIME TIME DATE DATE DATE ,,NS.ECTOR ,NSPECTOR 'NSPEO, DR MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE T DEPT. OF I;.~ALT, I &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC ~IRONMENT/,,L ;'L(J~ZCTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION MAR 6 1980 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEW~~IVI~ DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proce~ed. Please allow ten (10) days for pro~essing. 1. pROpERTY OWNER ~ROPERTY RESIDENT (If different from above) PHONE ~' PHONE 2, BUYER MAILING ADDRESS 4. REALTOR/AGENT J PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF~BEDROO-MS [] One [] Four [~ [] Two [] Five SINGLE FAMILY [] MULTIPLE FAMILY [~ Three [] Six /- oT //7/. [] Othe~ 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY PUBLIC UTILITY * ATTACH WELL LOG. A well log 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 l--I INDIVIDUAL/ON-SITE** /~) YEAR ON-SITE SYSTEM WAS INSTALLED. I~OTE: THE INSPECTION FEE MUST A~OMPANY 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 [] 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 [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line I I WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS [] APPROVED FOR BEDROOMS ~ CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY ~ 72-010 (Rev. 6/79) ~ ~i'~? INpIVIDUAL SEWAGE AND WATER FACILITIES I . ~J~f ' (Fill out in T~iplicate) /q ~' i ~' '~~.~.=-3~7~ Watez Analysis: b. Detergen~ c. Casin~ giz~ d. Dis?~nce fr.om well to clos~s~ existing or ppopose~: 2. Septic tank 4. Casspool~ ~ . 5. Pmoperty Line ~. O~,e~ ~ou~ o~ ~o=~ ~o~n~on, ~.e., ~e~, houses, baPn~ d~ainage dltch, etc. ~ . $~. b. Septic tank capacity in galions ~ . c. Name of septic tank manufactu, m~ ~ ~ 1. If "home made" show diagram on revePse side of this foPm. 1. Distance to p~ope~y, l.ln~ ' to house · .e, Percolati(xn. T~st'~results f. Percolation Test performed by Use the reverse.side of this form to show diagram. Diagram should include ~['%he fo] lowing information: ~operty lines;.well location, house location, ~,~qc tank location, disposal area location, location of percolation test, aud dJ~.ection of ground slope. 9. The ~"'r',~,a~;~m ,On this form is true and correct to the best of my knowledge. 'S'~g~ature 'of Applicant 'D'ate Si'~n'ed ~.B.E_ FILLED OUT BY HEALTH DEPART~.~,ENT PERSONNEl, · [-~ · The above described sanitary facilities are hereby approved, subje, c,t, ,to the .......... ~w_i~ng con~itions: ' Condition~ :~ ~. The above described sanitary facilities are disapproved for the following reasons: ~ ? Approval is valid for one year following the date of approval. CPJ: cw