HomeMy WebLinkAboutFALLING WATER BLK 3 LT 1Folling Water
Block 3
Lot 1
#050-772-07
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
lk c
PHONE
9�/_9�34
XNEW
CI UPGRADE
MAILING ADDRESS
S
LEGAL DESCRIPTION
41 68 aJ
LOCATION
h _
NO.OF BBEDROOMS
Um
DISTANCE TO:
Well
Absorption area
Dwelling f
�v1 �C"
PERMIT NO.
LZ
W
Manufacturer1 s. IC
C M
Material
AsbL
No. of compartments
Liq. capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
Y
_j 0z
DISTANCE TO:
Well
4
Dwelling
PERMIT NO.
_z
F
Manufacturer
Material
Liquid capacity in gallons
O
W =
DISTANCE TO:Nff
Well
Fe.
Foundation
t,=e,
Nearest lot line
PERMIT NO.
J U. Z
f z¢
No. of Iles
Length of ach line
—e
Total len th of lin
/c
Trench width
inches
Distance ¢e ween lines
�(J A
¢ F
O
Top of tile to finish grade
Material beneath tile d
p inches
Total eff ctive abs o tion area
3 ; ' e,
w
t7
Length
Width
Depth
PERMIT NO.
aF-
w IL
Type of crib
Crib diameter
/i J14
Crib depth
Total effective absorption area
W
DISTANCE TO:
Well f
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
W
W
r
DISTANCE T0:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
CA
SOIL TEST RATING
Qrn
5
it
/!
1
INSTALLEF? 11//
i46'tle /'DU5 iC1
REMARKS
S (4
71
4440
A R VED
L & /Z e,
DATE LEGAL
�//, f
12-013 �jF kv. 3/78) U
09!30;1997 14:03 9076965534 EAGLE DENTURES PAGE 01
� M -W DRILLING, INC.
irna�c
DRILLING LOG Q'4 w �-
well Owner
Brad & Paula Dickey 0J
14cation (address of: Township, Range, Section, if known; or distance
Lot 1 Block 3 Failing Water Subdivision,
Size of cas1ng 6_,, � nepth of Hole, 80 feet Cased to 80 feet
Static water level ft, (4) (below) land surface. Finish of well (check one) open and ( SLS );
Screen ( ) ; Perforated ( ) .
Describe screen or perforation NSA
Well pumping test at�_gatloaAs per (KAff (minute) for 1 hours with 100 t
of drawdown from static level.
Date of completion 812217d '�(YU
WILL LOG
Depth in feet from
ground surface ' Give details of formations penetrated, size of material, color and hardness
0 TO 2
Casing
stickup
2 To 15
Boulders
15 35
Loose
gravel
35 _To 40
Loose
gravel: damp
- -
_t 0 Tam_
Boulders
6i3
_Hard
pan
_To_
OCT 1 1997
72
Net sandy
gravel
__f&—To_
Municipality of Anchorage
__2.L_To__H_
Sandv�water
gravel
dept. Heaith & Human Servirrws _._.._._
TO
TO
—TO-
-TO-
O
TO
_
--TO
To—
TO
i -CUSTOMER
DEPHRTMEHT O� IEHLTH HND ENVIRONMENTHL FTECTION
825 'L' STREET, ANC:HORHGE/ HK01
264�4720
14 If__ t _ ���H -:::. ���:1 -1 F� �m:: p A R. : ::" 0 0 R � v
PERMIT NO. ( 780748 )
HPPLICHHT BRHD DIBOX 161�
LOCHTION MI 12 EAGLE RIVER RD
LEGH[ L1 B] FHLLING WHTER S/D
//J"�//
i'�
�
9.Ao'/"
|' /"arl
LOT SIZE ~�7000 SQUHRE FEET
TYFE OF SOIL HBSORBl* ION SYSTEM ISTRENCH
MHXIMUM NUMBER OF BEDRDOMS � ] SOIL RHTING (SQ FT/GR)� 100
THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM ISw
����9 'K.��
/
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIEL).
THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE 8ETWEEN THE SURFHCE OF THE
GROUND HND THE BOTTOM OF THE EXCHVHTION (IN FEET)
` THNO SET WIDTH FOR TRENCHES.
THE GRAYEL DEPTH IS THE MINIMUM DEPTH OF GRAEL BETWEEN THE OUTFHLL PIPE
HND THE BOTTOM OF THE EXCHVHTION (IN FEET)
����� ������ ��rA V:::::
PERMIT HPPLICHNT HHS THE TY TO INFORM THIS DEPHRTMENT DURING THE
INSTHLLHTION INSPECTIONS OF HNY WELLS ADJHCENT TO THIS PROPERTY HND THE
HUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
_�� �V".Ill T 11". .4 U."', r-4 1::::-p �A -I[ Ft",",��
BHCKFILLING OF HN; WITHOUT FINHL INSPECTION A41) BY THIS
DEPHRTMENT WILL BE SUBJECT TO PROSECUTION.
����1�� 1*��.1 IF;;�!! F� ��:: �lr�?_' : ::�]' --A ��;;:�:"�
I CERTIFY THHT
1� I HM FHmLImv HITH To: REQU/REMENTS FOR ON-SITE SEWERS HND WELLS HS SET
FORTH BY THE MUNICIPHLITY OF HNCHORHGE'
2� I WILL INSTHLL THE SYSTEM IN HCCORDHhlCE WITH THE CODES
]� I uNDERSTHND THHT THE OuSITE SEWER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE
RESIDENCE IS REMClDELFT) TO INCLUDE MORE THHN ] B�DRO��S
SIGNED
~~_���_.~��__
HPPLI��NT BRHDD����Y /
~
0 Et E GEO', .:CHNI CAL £t DEVEL,. PMENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Earl Ellis
Russell Oyster SOIL LOG 688-2280
694-2774 Land Development
Soils Et Foundations
Performed for: Name: Tel. No.
Mailing Address: -
Legal Description:-
Death_ (__ feet) Soil Characteristics
0
1
2
3
4
9.
11
X12
13
14
15
16
OF At
9
07-4
• o
n'
0 es °9oa°naa-oan nec°0000crtou vino
°e•°•moe°o•oo o°moo°ono eo nen •+
!r;
0, �'A e � Russell L. Oyster
A • No. 42&'6-C
h% PROFESS\�)"' v
Ground Water Encountered: Yes—__— No — If yes, what depth
Proposed Installation: Seepage Pit Drain Field
Comments:
Performed by: Date:
Municipality of Anchorage ••
Development Services Department
j Building Safety Division
On -Site Water 8 Wastewater Program >
4700 Bragaw Street p �/
P.O.Box 19
Anchorage, AK 99519519 -6650 L iJC,
www.muni.orglonsite
®� (907) 343-7904
�►► CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O573 -1 `'L IQ CosA# 01&21P'-3
1. GENERAL INFORMATION Expiration Date: .10 — D..5_ 2-7
Complete legal description FALLING WATER SUBDIVISION, LOT 1, BLOCK 3
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
2916 MISTY MOUNTAIN ROAD ' EAGLE RIVER AK 99577
TIM do ANNE REMICK Day phone 694-3216
2916 MISTY MOUNTAIN ROAD " EAGLE RIVER AK 99577
Day phone
BONNIE MEHNER w/PRUDENTIAL JACK wHRE Day phone 762-3110
3801 CENTERPOINT DR #200 • ANCHORAGE AK 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
❑
Individual Water Storage
❑
Individual Holding tank
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
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.
Address 3701 E. TUDOR ROAD, SURE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's 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 3 bedrooms.
Disapproved.
Phone 337-6179
Date Z3 O7
o.J f y G rness.-
Conditional approval for bedrooms, with the tllowing stipulations:
Attachments:
COSA Checklist Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Reort
Nitrate Advisory Other
.a
ONSITE
WATER AND
WASTEWATER :
PROGRAM
By: ��Original Certificate Date: f — .S— D 7
(Ra. 1tN5)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water S Wastewater Program
4700 Bragaw Street
P.O. Box 196660
Anchorage, AK 99519.8850
www.muni.orglonsits
(907) 343-79W
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: FALLING WATER SUBDMSION, LOT 1, BLOCK 3 Parcel ID: D._O — % 70. 0 %
A. WELL DATA
Well type PRIMATE If A, B, or C provide PWSID# N/A
Date completed 8/22/1978 Sanitary seal (YIN) YES
Total depth 80 ft. Cased to 80 ft.
FROM WELL LOG
Date of test 8/22/1978
Static water level UNKNOWN ft.
Well Log (YIN) YES
Wires properly protected (YIN) YES
Casing height (above ground) 12+ in.
AT INSPECTION
6/4/2007
49 ft,
Well production 5 g.p.m. 5.2 g.p.m.
WATER SAMPLE RESULTS:
'
Coliform oolonies/100 ml. Nitrate 0.04mg.IL. Other bacteria &6 coionies/100 mi.
Arsenic: N D ug./L. Date of sample: 6/4/2007 Collected by: GEG Ltd.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/FIBERGLASS Date Installed 8/24/1978
Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) YES
Foundation cleanout (YIN) YES Depression over tank (YM) NO High water alarm (YIN) N/A
Date of pumping 6/4/2007 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA
Date installed 8/24/1978 Soil rating (g.p.diteor� 100 System type TRENCH
Length 42 ft. Width 3 ft. Gravel below pipe 4 ft.
Total depth •8.91 ft. Elf. absorption area 336 ftt Monitoring tube YES Depression over field NO
Date of adequacy test 6/4/2007 Results (Pass/Fail) PASS Forbedrooms
Fluid depth in absorption field before test 1_5 In. Water added 495 gal. New depth 39.5 in.
Elapsed Time: 1101010 min. Final fluid depth 1 in. Absorption rate >= 450+ g,p.d.
Any rejuvenation treatment (past 12 mo.) (YIN 8 type) NONE KNOWN If yes, give date —
D. LIFT STATION
Date installed Size in gallons Manhole/Ac cess (YIN
"Pump on" level at _in. "Pump otP I High water alarm level at in.
Cycles tested Meets alarm 8 circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankfliR station on lot A t 00'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots
Public sewer main N/A
Sewer /septic service line 25'+
Public sewer manhole/cleanout
100'+
Holding tank N/A
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 1001+ Driveway, parkingivehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS I
10 I • F41•0 11 1 l -w -CO r+T I �ibP C 0#4T b'�- ��
G. ENGINEER'S CERTIFICATIONk-
.AzK�.••-
I certify that I have determined through field inspections and i;1'
review of Municipal records that the above systems are inconformance with MOA COSH guidelines in effect on this
date. ......y. r ssEngineers Printed Name JEFFREY A. GARNESSsn 79 t
Date Z� . a ••+
y11 �,
Yep.
COSA Fee S Y30 a- 1-75 )? US Waiver Fee E
Date of Payment �c�V%� Date of Payment
Receipt Number. 4 O O� Receipt Number
(Rev. 11M)
SGS RcLM
1072528001
All Dates/I'imcs are Alaska Standard Time
Client Name
Garness Engineering Group, Ltd.
Printed Daterrime
06/132007 16:21
Project Name/N
Falling Water LI D3
Collected Date/rime
06/042007 16:30
Client Sample ID
Falling Watcr Ll D3
Received Date/Time
06/052007 10:52
Matrix
Drinking Water
Technical Director
Stephen C. Fade
Ptt'SlD
0
Sample Remarks:
Paramettt
Metals by ICP/MS
Arsenic
Waters Department
Total Nilmtc/Nitritc-N
Results
ND 5.00
0.847 0.100
Allowable Prep Analysis
Units Method Container ID Limits Date Date Init
ug/L
EP200.8
C
(<10)
06/07/07 06/12/07
TK
mg/L
SM204500NO3-F
D
(<10)
06/09/07
1DS
Microbiology Laboratory
TotalColilorm 0 COV100mL SM209222B A (<1) 06/05/07 DLC
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section cm
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcell.D.# 050 772 07 " HAA#
1. GENERAL INFORMATION
Complete legal description FALLING WATER Ll B3
Location (site address or directions) 2916 MISTY MOUNTAIN ROAD ( 3rd House on left
Property owner STEVE & MARCIA WAKELAND Day phone
Mailing address 19048 MOUNTAIN POINT CIRCLE, EAGLE RIVER, AK
Lending agency Day phone
Mailing address
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well X
Community well
Public water
Day phone
242-4270
99577
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
SEP 3 0 1997
RECEIVED
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site X
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. 1/91) Front MOA#21
5. 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 forthe 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 Eadle River Engineering services Phone
Address P.O. Box 773294, Eagle River, AK 99577-3294
Engineer's signature
6. DHHS SIGNATURE
Approved for
Disapproved.
M
bedrooms.
694-5195
Date
9-30-97
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
m' r rztic fin(IW.
%UTIC
Date I0—CC5`�77
The Municipality of Anchorage Department of Health and 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 purchasers of homes
and their lending institutions in orderto 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-M (Rev. 1/91) Back MOA N21
"*K*ALlrr CW
Municipality of Anchorage's
DEPARTMENT OF HEALTH & HUMAN SERVICES &QVXZs
Environmental Services Division R 3 01997
825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 34
RECEIVED
Health Authority Approval Checklist
LcgalDcscription: 1,o'fl B/4'.? All, -;y W"A'e Parcell.D.: USO 773.07
A. WELL DATA
Well type Roeoy B rE If A. B, or C. attach ADEC letter. ADEC water system number N,
Log present (YM) i Date completed YIA n17 F
Total depth V) 1, Cased to ge '' Casing height (above ground) 3
Sanitary seal (Y/N) Wires properly protected (YIN) y
Date of test
FROM WELL LOG
.f/?y
Static water level 4N/r.✓
Well production ✓� Gr^^ g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 Nitrate 1. fs
AT INSPECTION
4. Other bacteria
Date of sample: 7 42 C /9c /9 7 Collected M.:�.
B. SEPTICMOLDING TANK DATA
Date installed _1 ? Tank size/O� Number of Compartments o9- Cleanouts (Y/N)_Y
Foundation cleanout (YM) Y Depression (YM) /J High water alarm (Y" A) 1.4
Date of Pumping 7'2 7 -9 7 Pumper JR f
C. ABSORPTION FOLD DATA
Date installed
1176'
Soil rating (al.44 'orfi'/bdrm) JeO Systemtype Treo-cA
Length <1 ZL r Width 3 1 Gravel thickness below pipe Y Total depth 9, e'
Effective absorption area 3 3 6 4b Monitoring Tube present(Y/N) i Depression oyer field (Y/N) V
Date of adequacy test 7 -.2A -'?7 Results (Pass/Fail) P+tJ For 3 bedrooms
Fluid depth in absorption field before test (in.); Immediately after�ogal. water added (in.): -40—
Fluid depth _0 (ins.) Minutes later:_ Absorption rate = Lo go g.p.d.
Peroxide treatment (past 12 months) (YIN) NIA If yes, give date
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N) "Pump on" level at*
High water alarm level at*
*Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
"Pump off' level at*
Septic/holding tank on lot 4#/yo ; On adjacent lots � / o4)
Absorption field on lot t/oo ' ; On adjacent lots f/ Vo
Public sewer main AJIA Public sewer manhole/cleanout W /A
Sewer /septic service line t S -o '
Lift station Al /4
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation a o 1 Property line t-10 ' Absorption field /D
Water main/service line t'10' Surface water/drainage ' Wells on adjacent lots �zuv r
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation Y -57 -'.
Water main/service line /o
Surface water -) /o
Curtain drain N 14
F. ENGINEER'S CERTIFICATION
Driveway, parking/vehicle storage area +i O
Wells on adjacent lots t eo o '
Property line / i /
I certify that I have determined thru field inspections and review of Municipal recorc0*Jhq( the'abtiv#,s
in conformance with MOA HAA guidelines in effect on this date.
ON, •, M,
dw
Signature *f497[1
�••wN! • N••••
Engineer's Name rh rlg• exl•
Louis A. Outere
Date 9�?v /S 7 #1�`'w. ,` CE -6736
HAA Fee $ eT96V • C4D Waiver Fee $ _
Date of Payment Date of Payment
Receipt Number � ( O l Receipt Number
Rev. 8/95 OSS: haa.wk.doc
are
SEP -30-1997 13:22 CTSE ESI ANCHORAGE
CTa,E Environrrtental Sarvicss Inc.
CTOkE Rd.0
Ment Name
project Name/#
Clem Sample ID
Matrix
Ordet'ed BY
Pwsw
975852002
Eagle River En&eering
NIA
Failing Water Lot 1 Blk 3
rtrinkin¢ Water
parawleter
aesu
0
9075615301 P. 03105
Client Po# 09129/97 12-09
�t�WTkue
p Time 09126197 09!05
Roceived Dotenlme 09/26/C Ede Techgtcal Dt wWr. Stephen
Reieamd BY
At►Owable Prep Anotysis
P0L
Method Limitc Date OetO In
�t
1.95 0.100 mg/L EPA 300.0 10 MAX
Nitrate -N 0.00 col/100et. 9416 92228
Totat COtifarm
09/26/97 CCP
09/26/97 T"Y
I
E
M Q r + W ✓ w�
U"'
' QS
I nF eb�^i''ra#�"tnF
MUNICIPALITY OF ANCHORAGE ENVIRONNr.0, ;" °_ "CTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
DCC1g1978 e
Q�
_ Telephone 264-4720
RECEIVED) 3
1•
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not he processed. Please allow ten (10) days for processing.
--------
-----
i. PROP Y OWNE�1R —(-------------------------_9._."7�1
2
M/A�^I''L'�I'�N ADDRESu�
PROPER Y RESIOE move) — - —�---
_---P
\^ 7
T (lf diff/etre�nt from
pq E
all wells
since June 1975. For wells drilled prior to that date, give well
C_1 PUBLIC UTILITY
2. BUYER
8. SEWAGE DISPOSAL SYSTEM
PHONE
MAILING ADDRESS -- i
individual/on-site, give installation date1
3. LENDING)fSTITUTIONPHONE
%
a.%7'-1 YS-?
MAILING ADDRESS ��—"---'��
a.���
by this Department.
4. REALfTOORIAAGENT //y �/� /;
—
PHONE--
0-217 Y3
MAILING AUDRESS -- "
6. LEGAL DESCRIPTION
STREE LOCATION
6. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
SINGLE FAMILY
One ❑ Four Other"
E7 MULTIPLE FAMILY
CJ Two ❑ Five
❑ Three C_l Six
7. WATER SUPPLY
INDIVIDUAL` "ATTACH
WELL LOG. A well log is required for drilled
_1 COMMUNITY
all wells
since June 1975. For wells drilled prior to that date, give well
C_1 PUBLIC UTILITY
depth (attach log if available.) 1R
8. SEWAGE DISPOSAL SYSTEM
.INDIVIDUAL/ON-SITE"" "'If
individual/on-site, give installation date1
C.I PUBLIC UTILITY
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,
72-01013/781
WN
72-010 Mev. 3/ 31
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME
TIME
TIME
.-------
_DA_T
E
INSPECTOR
INSPECTOR
INSPECTOR
1 TYPE OF RESIDENCE
OF BEDROOMS
--NUMBER
El SINGLE FAMILY
F-1 ONE 0 THREE
❑ FIVE OTHER
E] MULTIPLE FAMILY
0 TWO EI FOUR
C1 six
PERMIT NUMBER
2. WATER SUPPLY
El INDIVIDUAL
—6—EPT14OF WELL -
COMMUNITY
DATE DRILLED
El PUBLIC UTILITY
Connection Verified,___
I -OG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
PERMIT NUMBER
E] INDIVIDUAL/ON -SITE
UATE INSTALLED
E—] PUBLIC UTILITY
Connection Verified ied
INSTALLER
U1 Septic Tank or ED Holding Tank
9 0 If Tank is homemade
Size: JAN
SOILS RATIGjN
give dimensions:
MANUFA TUBER
TYPE OF TANK
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
Septic/Holding Tank Absorption Area
Sewer Linc Nearest Lot Line
WELL TO:
_
7_13so, rltio_n Area to nearestLotLin_e________
5. COMMENTS
At.
Z�-'APPROVED FOR
BEDROOMS
D CONDITIONAL APPROVAL
(letter must accompany certificate)
U,DISAPPROVED
DATE--
BY (Title)
LEGAL IDESCRIPTION
LEGAL
72-010 Mev. 3/ 31