HomeMy WebLinkAboutCONIFER HEIGHTS BLK 1 LT 22GREA,r:i.. ANCHORAGE AREA BOR~dl
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING ADDRESS
LEGAL DESCRiPTION '/'~ ,~/~
SEPTIC TANK:
DISTANCE i ~ NUMBER OF /
FROM WELL //~2 MANUFACTURER ~ MATERIAL COMPARTMENTS
INSIDE WIDTH
INSIDE LENGTH
LIQUID DEPTH '-~ LIQUID CAPACITY/g~OOGALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELL///~ '-/"' FOUNDATION /~ '7/-' NEAREST LOT LINE //~7 /
NUMBER OFL,NES ! D,STANCE BETWEEN L,NES /Y/~ TRENCH W,DTH-~<:;
~'"~5~'O /,~ LENGTH OF EACH LINE ~ ~ '
DEPTH: TOP OF TILE T~I~I~H GRADE ~ MATERIAL BENEATH TILE __ IN. ABOVE TILE
TOTAL LENGTH~
OF LINES
IN. TOTAL EFFECTIVE
TYPE __~ CON ST R UCT IO N
BUILDING NEAREST NEAREST
FOUNDATION__ LOT LINE__ SEWER LINE__
CESSPOOL , OTHER SOURCES
APPROVED_ DISAPPROVED REMARKS
DEPTH
SEPTIC SEEPAGE
, TANK__, SYSTEM
DISTANCE FROM:
DISTANCES: (~r ~'~,
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
f /
Form EQ-032
DIAGRAM OF SYSTEM
,', '~,. ,~)
r~,,.,:-~ ,:, ,'
DATE ///~' ~' 7 ~>'~ APP ROV ED '~- ~/~G.~
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED
FINANCED THROUGH
OTHER
NOTE; THIS PERMIT !$ NOT VALID WITHOUT SOIL. TEST
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REC)UIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL C}UALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
DIAGRAM OF SYSTEM
SEPTIC TANK SIZE ~ YPE
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
SEPTIC TANK TO SEEPAGE PIT WALL -- /-- ~*
SEPTIC TANK ~'~ ~' ~ O
. SEEPAGE PIT , DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK /~'~ ~ SEEPAGE PiT
WATER MAiN TO 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 IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PiT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REG. I~JLATIONS REGARDING INSTALLATION.
OR
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF (~EATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE I I [~
DATE, APPLICANT'S SIGNA
FORM NO. EQ-01 6
CONSULTANTS, INC.
ANCHORAGE
FAIRBANKS
JUNEAU
249 EAST 51ST AVENUE * P.O. BOX 6087 · ANCHORAGE, ALASKA 99503 · TELEPHONE 907-279-0483 · TELEX 090-35419
September 13, 1974
Mr. Jim Hooser
5307 Caribou Avenue
Anchorage, Alaska
99504
R & M No. 462075
Re: Test Hole and Soil Log Report for Sanitary System
Lot 22 Block 1, Conifer Heights Sub-Division
Dear Mr. Hooser:
We are submitting herewith the test boring results and our comments
regarding soil conditions encountered at the subject site. This
investigation was performed in accordance with your request of September
6, 1974 and those procedures outlined in a letter dated September 13, 1971
by Mr. Rolf Strickland of the Greater Anchorage Area Borough Department of
Environmental Quality.
A single test hole was put down within the Lot 22 area for the purpose of
defining general subsurface soil conditions for the proposed sanitary system.
Excavation was accomplished with an auger type drilling rig, and the test
hole was extended to a total depth of 16.0 feet below ground surface.
The final log prepared for the test hole has been included in Drawing A-01.
Ground water was not encountered in the test hole.
We appreciate being given this opportunity to be of service to you.
Should you have any questions with regard to the above, please do not
hesitate to contact us.
Very truly yours,
R & M CONSULTANTS, INC.
JWR:rr
xc: GAAB
TH-1
~-6-7q
0o0!
ORGANICS
, 0.5'
, I .O'
SILTY SAND TRACE GRAVEL (SM)
SILT TRACE SAND (ML)
6.01
7.5'
SILTY SAND TRACE GRAVEL (SM)
16.0'
NO WATER TABLE
NOTE: Test hole extended with auger type drilling rig.
V Engineering I~ Geological Consultants Inc.
ANCHORAGE FAIRBANKS ALASKA .,UN~^U
Jim Hooser Property
Log of Test Boring
Anchorage, Alaska
DATE
D042275
SCALE I": 2' DWN aY B.H.
I c.~<o .',' W.E.D. 1~,,oo. NO. 462075, I°wa No.A-OI,
Parcel I.D.
1. GENERAL INFORMATION (Must be completed prior to submittal)
M U,bN~Cl PALITY., ,~ OF ANCHORAGE.
Del~ttment of Health & Human Services
;ION OF ENVIRONMENTAL SERVICES
343-4744
iON FOR HEALTH AUTHORITY APPROVAL OF
FACILITY FOR SINGLE FAMILY DWELLING
HAA # ~ ~,"~o~ ~, ('%~_~[c~
(a) Legal Description (include lOt, block, subdivision, section, township, range)
Location (address or. directions)
(b) Property owner
Mailing Address
Telephone' (home)
Co, 2 o/
Telephone
(c) Lending Institution J~, ~,
Business
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone ?~8- ~[ l~
/+/-c
(e) Mail the HAA to the following'address: (or check here ~, if hold for pick' Up.) ,:":,- '
List contact person and day phone number below: t~!."' ;.i i..',.
t," , ~..'! I
2. TYPE, OF RESIDENCE
Single-Family ~ Number of bedrooms ~ ''~
3. WATER SUPPLY
Individual Well I~ CommunitY r-I Public []
Note:df. community.` well ,system, ,must have wr tten confirmation, from the State.DePartment of Environmental
- sEWAGE DISPOSAL ':"' .
.On-site ~: ~,,Public [] ~:': Community [] Holding Tank [] '" ' . '
NOte: ~1~ ~m'&'u'"ity well s~stemi'rnuSt'have wriiten C°nfir~ati°n from the State DePartment of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page i of 2
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A. WELL DATA
Well Classification
Well Log Present (Y/N) ¥ Date Completed
Total Depth 3~JC)' Cased to
Static Water Level j c/O'
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
MUNICIPALITY Of ANCHORAGE (MOA) ~
Health Authority Approval (HAA)
CHECKLIST ,,FEBRUARY 1984
343-4744
io~.%'5'' Legal Description: L. 22. ~J £ON~FER
If A, B, C, D.E.C. Approved (Y/N)
~/2,.o/'7'-/- Yield ~o,~ ~Pkl
Depth of Grouting H, P~,
I
Pump Set At ~ ;2 5'5
Sanitary Seal on Casing (Y/N) ~/
Depression Around Wellhead (Y/N) I'~
To Septic/Holding Tank on Lot ii2.' TO ¢,0, ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ~ ]0O/ , ; On Adjoining Lots
To Nearest Public Sewer Line ~' Icc ~ To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ~
Water Sample Collected by F/.-/~T3'OP '~ECH .SCV..%. ;Date
Water Sample Test Results ~ATI.SP,~CTOR.¥' N,D, ~,.~/,~ N~T~rTE N
T~3 C .O,
I0'-/' ~To C.O~
~ /o0~
B. SEPTIC/HOLDING TANK DATA
Date Installed /0/'/5 Size /o~ G~No. of Compartments
Standpipes (Y/N) ~ Air-tight Caps (Y/N) Y
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Foundation Cleanout (Y/N) t",\
Date Last Pumped 2/28/~1 BY tSA~qc~
Holding Tank High-Water Alarm (Y/N) 1~, A, Temporary Holding Tank Permit (Y/N) N. A,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well I
To Property Line ~O~ ~=~oM C,O.
To Water Main/Service Line
ti{:),
To Stream, Pond, Lake or Major Drainage Course
To Building Foundation ~0 TO C,o,
To Disposal Field ~' 1Co ~
I
~ Ioo
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed I o ,/'~.5'
Width of Field 3 /
25'o n'/Et)gN
Square Feet of Absortion Area 750 r~
Depression over Field (Y/N)
Results of Last Adequacy Test ~b~r
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot N, ~,
To Water Main/Service Line
C.o'
Type of System Design.
Length of Field (o 3 '
Depth of Field
Gravel Bed ThiCkness
~sP. ~eP Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line 2~'
To Existing or Abandoned System on
;On Adjoining Lots ~ 3o'
]=~o~ C.o, To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course ~, /oo'
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~ ~'Rt~v'EI. ~ pTH NoT ~t4 b~cA'r'£t~ o VYtLv&$
D. LIFT STATION
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Pumping Cycles during Adequacy Test.
Comments
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA.(jlCl~t~l~'h~ffect on the date of this
inspection. . ~_a_~(~¢. _~. ~ ~, .,,~------'* ' ~
Signed ~~ ~ ~ ~..~ ,~."' ~ '"?~..~ _~.
Company ~/a~ T~CAn,'~/ Xer~td~ 5'"v'. : '~.gt~ '~ /"~t""
~eee~e~eeee~eeee~e~
Date ~ ~ ~ /~ ~ ' ~~Z~- ~~:L[ Eng,neers Seal
MOA NO. ~ ~ -O (~ ~ ~'~5~A '?~<~.& ~ ~'":'w' ' ';~* ' '* g'~-' % ~ rHEODO~E" ' "' · -- '..CE '......' - 3589 F . ., '*OO,E ~ · ."
Receipt No.~,~ ~ ~0~) Receipt No. ~~--
/
Date of Payment - ~ Waiver Fee: $ ~ ~
Amount: $ /~0 ~ Date of Payment ~ ~ -~/
72-026 (Rev. 7/88) Back Page 2 of 2
unicip lity of nChora e
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
July 18, 1991
Ted Moore, P. E.
Flattop Tehcnical Services
14530 Echo Street
Anchorage, Alaska 99516
Subject:
Waiver Request for Lot 22 Block 1 Conifer Heights S/D
Waiver Request ~WR910009, PID #015-093-54, HA910068
Dear Mr. Moore:
Your request for waiver of the required 100 foot horizontal
separation of a septic system to a private well has been approved.
The approved separation distance is 94 feet from the well on Lot 22
Block 2 to the septic tank on Lot 19 Block 1 Conifer Heights S/D.
This waiver approval applies to the existing septic system to
well separation only. Any future upgrade to either will
require all separation distances be met or another approval
from this department.
Sincerely,
Daniel J. Roth
Civil Engineer
On-site Services
Concur: / ~
~!~!!itg~ ~i! grvr .al cms sMan a gel~ r'J
DJR/ljm ~6
unicipality of Anchorage
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. BOX 196650 Anchorage, Alaska 99519-6650
April 18, 1991
Theodore F. Moore, P.E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Re: Waiver Request WR910009 & Health Authority Approval
Application HA910068 For Lot 22, Block 1 Conifer Hts. Subd.
Dear Mro Moore:
As part of this office's evaluation of the subject waiver
request and Health Authority Approval application, this office
performed an on-site inspection. While at the site, it was
noted that there were two distinct parking areas and two
exterior entrances to the dwelling. .During the site visit we
spoke to a gentleman who identified himself as being from the
property management company that was caring for this dwelling.
He allowed us access to the interior of~the structure where we
noted two separate living units complete with.kitchens,
bathrooms and sleeping accommodations with a locking door
between the upstairs and downstairs units. It was apparent that
the dwelling was set up as a duplex.
Based on a preliminary evaluation, it~appears that both the
waiver and Health Authority Approval a~plicatioa can be approved
for a single family dwelling~ However, as you know, this office
cannot approve waivers or Health Authority Approvals for
multi-family dwellings. To convert this dwelling to a single
family residence, a kitchen must be removed and an unobstructed
passage must be constructed between the upstairs and the
downstairs units.
This office is unable to take any further action on either the
waiver request or Health Authority Approval application until
the conversion of the duplex to single family is complete.
If you have questions, please call 343-4744.
Si n , /?
~r~oh(~ r Sa mmi ~ ah~
On-Site Services
cc: Daniel Roth, Civil Engineer, On-Site Services
"Kids Are Our Future"
MUNICIPALITY OF ANCHORAGE
MEMORANDUM
DATE:
TO:
FROM:
SUBJECT:
April 10, 1991
John Smith, P.E., Program Manager, On-Site Services
Daniel Roth, Civil Engineer On-Site Services Progra~
Lot 22 Block 1 Conifer Heights Duplex Conversion
The subject Waiver Application/Health Authority Approval was
recently submitted to this office. A site visit was made and it
was apparent that this residence is a duplex. Upon entry it was
further noted that two complete kitchens existed and a door
between the two units that could only be opened with a key in a
dead bolt lock.
This scenario is becoming more common as this office makes more
site visits. The engineers are obviously ignoring the fact that
these structures are fully equipped duplexes. Many engineers are
believing the realtors who tell them that the duplex will be
converted when the new owners finish closing on the properties.
I do not believe the conversions are always happening because of
all the illegal duplexes we find.
As reflected in the attached letter, a precedent was set by this
office to an engineer to hold his application until the physical
conversion of the duplex has taken place (i.e. total removal of
the kitchen and opening a permanent interior access between the
two units). In the interest of this office maintaining
consistency in the issuance of approvals to the engineering
community, I am not going to issue the subject waiver application
and Health Authority Approval and I will return it to the
engineer to hold until we can make an inspection of the structure
to verify the complete conversion has been made prior to our
issuing any approvals.
/ unicipal:ity of Anchorafle
Department of Health and Human Services
825 "L" Street
Tom Fink, '
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
March 8, 1990
Robert A. sharer, P.E. and Richard Shafer
S & S Engineering/Tweed Excavating
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject: T12N R3W Section 15 Lot 35
PID #015-052-03
Gentlemen:
On March 5, 1990 this office made a site visit to the subject
property. At that time it was noted that considerable work had
been completed in the construction of a new on-site wastewater
disposal system. The septic tank had already been set in the
ground and backfilled and excavation for the new trench system
had commenced. At the .time of the site visit, a permit for
construction of the wastewater disposal system had not yet been
issued by this office.
Anchorage Municipal Code, Chapter 15.65.120, Subsection A,
states:
"A person may not install, nor modify an on-site wastewater
disposal system, earth privy or vault privy without first
obtaining a permit from the department. A separate permit
is required for each installation, modification of an
on-site wastewater disposal system, or vault privy."
This office expects the highest standards of code compliance
from engineers and excavators who design and install on-site
systems on a regular and frequent basis.
Please be advised that this office takes exception to
construction of wastewater disposal systems without first
obtaining a permit. Future violations may result in a citation
being issued to you and attendant court action.
"Kids Are Our Future"
Robert A.Shafer, P.E.
Richard Shafer
February 8, 1990
Page Two
Also, during the sTte visit, it was visually apparent that the
structure on the property was a duplex. Although we understand
'~that the structure is currently being converted to a single
family residence, we would like to remind you that this office
does not have authority to issue permits for the construction of
on-site wastewater systems which serve more that a single famil3
residence. In the future, please make sure that the physical
conversion of the structure, from duplex to single family,' is
completed prior to submitting a permit application for a single
family system.
If there are any questions, please call our office at 343-4744.
Sincerely,~
~~~a~; On-site Services
cc: Lee Browning, P.E., Manager, Environmental Services
Dan Roth, Civil Engineer, On-site Services
RPR 05 ~91 10:55 ~RCK ~HITE CO RHCH
Fax; Oomrnemi&l ~61.7137
RMIdentlal 561.713~
P.1
](unioipality of ~nchorage
RS:'Xntended Uae
Dear )tr. Smith:
As per your request, Z will address the future usage of
re£erenoed property to the ~eat ct my ability. X represent
· uget Sound Bankj Ge current owner o£ the'referenced
proper~y. The property' was used as a collateral on a loan. to
a Mr. Neeserl ~he £or~er owner o£ ~he proper~y. Mr.
apparently used the property as a duplexl in clear violation
of zoning for that property, l~Aget ~ound Bank was unaware
that use. ~r. Neeaer did not reside at ~.he property.
The property is under contract Co be sold to Adrian and
Cynthia ~Caa. The McCaa's have represented to me that they
in,end to gut and completely remodel ~he property for use aa
~heir residence. Mr. Mccaa ~old me ~ltat he has no intent to
ever rent a p~cion o£ the property. ! cannot guarantee that
this will ~e ~he case but ! dO believe Mr. MoCaa.
:]:f you~h_a~ questions, please don't hesitate to con,act me.
Foe LoT
2'2.
x
CIVIL & ENVIRONMENTAL ENGINEERING * ENERGY CONSERVATION & ANALYSIS
THEODORE F. MOORE, P.E.
PH: (907) 345-1355
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
March 5, 1991
RE: Lot 22, Block 1, Conifer Heights - separation distance waiver
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
RECEIVED
MAR 6 1991
Municipality of,~tncho~:age
Dept. Health & Htmlan Services
Dear Sirs:
By means of this letter we are requesting a waiver of the normally required 100 foot separation
distance between wells and septic system components down to 94 feet between the well on Lot 22, Block
1, Conifer Heights and the 500 gallon septic tank on Lot 19. A site plan depicting the relative locations of
pertinent features is enclosed, along with copies of other relevant backup documents.
According to the driller's log, the well on the subject lot was completed in September of 1974 and is
cased to 238 feet with the bore hole extending down to 390 feet in bedrock. On February 28 the static
water level stood at 190 feet below the top of the casing. To assess it's yield we pumped a total of 858
gallons of water from the well at the maximum pump output of 6.9 gpm. This caused a gradual
drawdown of the water level inside the casing to 253 feet with good recovery after the pumping was
stopped. Water samples taken on January 22 were satisfactory, showing 0 coliform or other bacteria per
100 ml., and non-detectable nitrates.
The original wastewater disposal system on Lot 19 appears to have been constructed entirely outside
the 100 foot radius from the subject well. In 1983 the system was upgraded by the addition of a second
500 gallon septic tank and additional soil absorption trench. The new trench is also outside the 100 foot
radius, however we measured the distance from the cleanout of the 500 gallon septic tank to the subject
well to be 97 feet. This waiver request for 94 feet is to allow for underground projection of the tank
towards the well.
Several factors indicate that the granting of the requested waiver will not compromise public health.
The soils logs for both Lots 22 and 23 indicate silty sand to 16 feet with no groundwater table. On
February 21 we dug another test hole at the location shown on the site plan which also confirmed silty
sands to 16 feet and no groundwater table. The silty sand material has a measured perc rate of 40 minutes
per inch and thus can be expected to provide excellent filtration at a relatively slow rate, thereby protecting
the aquifer. The topography in the area slopes to the west at approximately 5%. While this is towards the
well from the septic tank, it is gentle enough that any effluent surfacing from a leaking septic tank will
have ample opportunity to be reabsorbed before approaching the well. Based on the fact that the well log
for Lot 19 reports the static water level to be at 185 feet vs. 190 feet on the subject lot, one can safely
surmise that the slope of the aquifer parallels the surface slope.
The following is a breakdown of how points could be assigned using the Separation Distance Waiver
Guidelines promulgated by D.E.C.'s SCRO.
Description Points
Distance to water table (185'-10' = 175')
Soil sorbtion (mostly sand with small amounts of clay)
Permeability (mostly fine sand with some silt)
Water table gradient (-5%)
Horizontal separation (94q
Total
7.4
2.5
1.5
2.0
2.8
16.2
Based on the above points the waiver appears to be justifiable. Please give me a call if you have any
questions on this analysis.
cc: Leonard Hyde - Jack White Co.
Sincerely,
Ted Moore, P.E.
LoT 21
TEST HoLE
LoT 7- '5
LoT 20
h/ELL
LoT ICl
~.. oP,~ Gl ~A L IoooG
~ovS£
, /
L22 BI
CON l FER
PLAN
HT.S
,.,qCALE: I"-- 5o~
bATE'
NOTE: TH iS ts blot
A SuE VE"/E b
ALL LoC/~-r ioNS
,ApPRoX I
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
S~
C. oN I FER
"JF. LLob/' l$ H
SILTy ~ANb
$1L'r¥ S~Nb
SoME G~'AVE L
COMMENTS ~.T, t N STA/. Z ~' b TO
LoAmY
Township, Range, Section:
SITE PLAN
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT L
DEPTH? O
P
E
Depth lo Watei Alter I~i' ~ Dr y
Monitoring? Date: ~ / ~,8/91
Reading Date Gross Net _ Depth to Net
Time Time <~iN'~ Water Drop IN
~ ~2o 2:oo:q~ 2~
PERCOLATION RATE ~0 (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~o,O. FT AND , ~o..-~" FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev, 4/851
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: "~-('Z ~ (9/
MUNICfPALITY
ENVIRONMENTAL ENGINEERING DIVISION NOV 2 ! 1978
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~br'l~_l~l~'['1
MUNICIPALITY OF ANCHORAGE ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT. I.C~N DEPT. OF HEALTH^
&
EI~VIRONMENTAL F ~OTECTION
825 L Street - Anchorage, Alaska 99501
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
'1', PROPERTY OWNEjR I,~' PHONE
I I!,'I R ,'l/Iv[
PROPERTY R ES ID ENT (-~ ~f~.r-~nt f--~-o~ ~b~'ve~' PHONE
PHONE
PHONE
5;--LEGA L DESCRIPTION
STP E ~T ~.0C/~TI ON
6. TYPE OF RESIDEI(ICE ..... NUMBER OF BEDROOMS
[] One [] Four
~.~ SINGLE FAMILY [] Two [] Five
[] ' MULTIPLE FAMILY [~ Three [] Six
[] Other
7. WATER SUPPLY
I
NDIVIDUAL'*
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
[~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
**If individual/on-site, give installation date I,O-~.,~--~ ~..'~
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
TIME
INSPECTION APPOI NTM ENTS
· ' TIME
DATE RECEIVED
TIME
DATE DATE DATE
'~ NSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
NUMBER OF BEDROOMS
1, TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[]INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
E~Septic Tank or E~Holding Tank
Size: [(~) If Tank is homemade
give dimensions:
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
[] OTHER
DATE INSTALLED
INSTALLER
SOILS RATING
M~ATERIAL~
Septic/Holding Tank IAb~::)rption Area lSewer Line
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
INearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
[] APPROVED FOR BEDROOMS
LEGAL DESCRIPTION
CONDITIONAL APPROVAL (letter must accompany certificate)
DISAPPROVED '
72-010 (Rev. 3/78)