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HomeMy WebLinkAboutSUNDI LAKE BLK 2 LT 14 ~/,j 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 LOCATION I Well I Absorption area DISTANCE TO: ~{~ [ '~ (~' ~'- Dwelling ~ · W dth NO. OF BEDIMS PERMIT N~ ~0 ~Z~'~ No. of oor,~rt,~ent~ Lic DISTANCE TO: IF HOMEMADE: Well Well DISTANCE TO: Length of each Top of tile to finish grade Total length of 1~]9~e~.~'- J Trench wi(l~h /~_ ~ ,-~-~ ~T" Material beneath tile ~ iTt'drtes Liquid depth PERMIT NO. PERMIT NO. ~'oo / 75-~ Length Width Depth PERMIT NO. ~e of crib Crib diameter Crib depth Well Building foundation Nearest lot line DISTANCE TO: Depth Driller Ruilding found~t~ t DISTANCE TO: Sewerline ~ (S(~l Total effective absorption area Distance to.~t li(~ PERMIT NO.~) Septic tal~_ [~ ~ / Absorption OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS APPR OV ED DATE LEGAL 72-013 (Rev~3'/78) ~ Permit No. 2 Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: SUNDI LAKE SUBDIVISION, BLOCK 2, LOT lt~lDNo.: 2 ADDEI~ C.O. AFTER :ULVERT &: BEFiORE TRENCH BEEN iVERIFIED ALL HATER TIGHT COUPUINGS INSTALLED MANHOLE .C.O ........................ 6OVER ........ i_ 24"gi CULVERT C,M,P, · .ST.· i WATER COUPLING N.T.E i 1000 GAL, iSEPTIC TANK RT EMBEDDED IN CONCRETE ~ .......... ~T ...................................... :CO ENGI PERMIT NO. fiPPLICfiNT LOCATION LEGAL I"llI-Jl"~ Z C: ]~ P FtL Z T%'" OF- I-"--I N C H IL"~ R Ft G E . DEPnRTMENT ~ ..... ,- . ~ ,~ ~ , PlELL flP'~O' OP~--S I TE SEPIER PER~ ~T' r --' DENNIS BROMLEY SR SUNDI DRIVE . LOT, ~4 8LK ~: SuNDi LAKE SUB LOT SI~- 42~ SQU~RE FEET TYPE OF SOIL fiBSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ FT/BR)= '125 THE REQUIRED SI/Z/~THE SI]IlL ABSrIRPTION SYSTEM IS: DEPTH= ~-~ LEP4GTH= 92 ]9RA%~EL DEF'TH= THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRfiINFIELD. THE DEPTH OF fi TRENCH OR PIT IS THE DISTfiNCE BETWEEN THE SURFACE OF THE GROUND fiND-THE BOTTOM OF THE EXCfiVfiTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRfiVEL BETWEEN THE OUTFfiLL PIPE fiND THE BOTTOM OF THE EXCfiVATION (IN FEET). F." E C:'4Li 1' AEC) SEPT I C: Ti=li'-.IK S I ZE= :I.£-~OO GFILLONS PERMIT fiPPLICfiNT HAS THE RESPONSIBILITY TO INFORM THIS DEPfiRTMENT DURING THE INSTfiLLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THfiT THE WELL WILL SERVE, TWO ( ~- ) I I~tSPEa-':T I C~NS RRE REi~LI I RED, BACKFILLING OF fiNY SYSTEM HITHOUT FINAL INSPECTION fiNE:., RPF'ROVfiL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND fiNY ON-SITE SEWRGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVfiTE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRIVfiTE WELL TO A PRIVfiTE SEWER LINE IS 25 FEET fiND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS fiRE REQUIRED AND MUST BE RETURNED TO THE DEPfiRTMENT WITHIN 30 DfiYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MfiY APPLY. SPECIFICfiTIONS fiND CONSTRUCTION DIAGRAMS ARE fiVfiILfiBLE TO INSURE PROPER INSTfiLLfiTION. ! PER~dlT E~-:F'IRES C. ECEi~iBER Zl.. ~L-~88 I CERTIFY THfiT · ; I AM FfiMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS fiND WELLS fiS SET ' FORTH BY THE MUNICIPALITY OF fiNCHOR~GE. ! 2; I WILL INSTBLL THE SYSTEM IN fiCCORDANCE WITH THE CODES. ~: I UNDERSTfiND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE ~ RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS. S I GNED: ........................................ fiPPLICfiNT DENNIS BROMLEb' V4. O ,I~L LO~ ~ ~EIDUI~D ~ D~.~r ~ ~I'URI~EO t'O THE DEP~RTfl~F THE D~L, COD~t. EFION. ~; I ~4~LL. t~r~.L T~ ~¢~TEH IN F.;~O~.~ t~{~l THE ~E~IC~,tCE 1~ ~b~DOEL.ED TO Ib~OE /'~ r~ 3 ls~JaO 8; ....... ¢ SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION [] PERCOLATION TEST Pouch 6~650, Anchorage, Alaska 99150'2 276-222'~ SOILS LOG - PERCOLATION TEST 1 2 3 4 5 6- 7- ~---,8- SLOPE SITE PLAN __ I- rl_._~l i J_ _.~ i 10,-, 11' 16., ,¢..__, 16 17 18. 19- 20- WAS GROUND WATER &~ ENCOUNTERED? ~'~ ~) IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (minutes/inch) t TEST RUN BETWEEN FT A D PERFO"MED BY: ~ ~ ~. ~ ~ CERTIFIEDBY;~ ~~~ DATE: 72-008 (7/76) 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ParcelI,D.# 011-13~18 HAA# HA930684 1. GENERAL INFORMATION Complete legaldescription Lot 14 Block 2 Sundi Lake Subdivision Location (site address or directions) 4849 Sundi Drive Property owner Dennis Bromle¥ Day phone 243-7342 (h) 522-3031 (w) Mailing address 4849 Sundi Drive Anchorage Alaska 99502 Lending agency Day phone Mailing address Agent Day phone Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. Three (3) NOTE: Individual well xxxxxx Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site xxxxxx Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) Fronl 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 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. NameofFirm s & S'Enqineerinq Phone 694-2979 Address 17034 Eagle River Loop Road, Suite 204 Eagle River, Ak 99577 Engineer's signature Date DHHS SIGNATURE xxxx Approved for three (3) Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: AdditionalComments This department has received written confirmation from the engineer regarding the Conditional Approval of 12-7-93. The corrections have been accomplished and an inspection has been completed by the engineer. The subject property meets with Mun~p~l q~d~ an~ ~s n~w app~ve~_ 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 order to satisfy certain federal and state requirements. Em ployees 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) Back MOA #21 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. December 21, 1993 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 RECEIVED HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECT[ON & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & ~.IECHANICAL INSPECTIONS ON SiTE WASTE WATER DISPOSAL SYSTEM DESIGN Munieipa~y of Anchorage Dep~2~ment of He~th and Human Services P.O. Box 196650 Anchorage, AK 99519 DEC 7 1993 Municipa!ity ot Anchorage Dept. Health & Human Services REFERENCE: Lot I; Block 2; Sundi Lake Subdivision 4849 Sundi D~ive ~ (~ ~ / 3 ~-/~ A Conditional H~alth Authority Approval (HAA) was issued on December 7, 1993, for the referenced property. A~l work required for the ¢ond,C~or~l HAA haz been completed. Attached is the 0n-sdte Wastewat~r Disposal System and/or Well Inspection Report for your approval. We request you issue a Fin~ Health A~ho~ty Approval for the referenced property. If you have any questions ENC LOSURES or require any additional information, 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ~\-\~,\- ~-~,- (~(L~) HAA# t~t'~°t'~o~\ GENERAL INFORMATION Complete legal description Lot 141 Block 2~ Sundi La'ke"$ubdivision Location (site address or directions) 4849 Sundi Drive Property owner Mailing address Lending agency Mailing address Agent Address Dennis Bromley 4849 Sundi D~ve Anchoraqe, Day phone AK 99502 Day phone 243-7342 (h) $22-3031 (w) Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: X×X 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. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX 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. 72~25 (Rev. 1/91) F¢ont 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 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 flies 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 S & ~ "'~GiN~,-~iNG ~ ~-~ Phone ,/~//'-~-~?? ~7034 ~gl. RiVer Loop fingineer's signature Date DHHS SIGNATURE Approved' for bedrooms. __ Disapproved. .Co~nditional approval for "~/'~--~bedrooms, with the following~ stipulations: ,.2 Additional Comments ~ ~'~ Date /,;z-7'--~'~ By: 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 DH HS 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 responsible for errors or omissions in the professio,~al engineer's work. 72-025(Rev. 1/91) Back MOA#21 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. December 7, 1993 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXI'ENS[ONS SEWER &WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ~ ROAO DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECFIONS MUNICIPALITY OF ANCHORAGE Department of Health and Human Services Attn: Susan 0swalt P.O. Box 196650 Anchorage, AK 99519 O ~'/-- [ '~,/-- / °~' REFERENCE: Lot 14; Block 2; Sundi Lake Subdivision Since the Zabel Filter was installed on this system without inspection or documentation it will be necesary to expose couplings to verif~ water type integrity. This work can not reasonably be accomplished until Spring. Therefore request you issue the Health Authority Approval on a co~diti~n~ basis with v~rification of the Zab~l Filter prior t~o~l~'' J~y, 199~4~'~ If we may~ further service, please contact us. ENCLOSURES RECEIVED DEC 7 199 Munic~pah[y of Anchorage Dept. Health & Human Services ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Legal Description: A. Well Data well pe L°g presen'~/N) Total depth ~ ( Sanita~ se~) Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST /~_~ 2_ ~'~[ L,~/~g' Parcel I.D. ~ //- / If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~ ["~/0~0 Driller-~'/~-) Cased to ,~/r~,~'-' Casing height Wires properly protected~N) ~'~--~ FROM WELL LOG Date 0f test Static water level ~7-~' Well flow Pump level1 /"//'~--- AT INSPECTION g.p.m. /-/~ ~'- g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/hc',d[~,g tank on lot /~,-~ f'~ Absorption field on lot Public sewer main ,~0~]/_. Sewer service line /(..1~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: ~o - ?--~' -' ¢15 B, SEPTIC/t,I~I~i~TANK DATA Date installed _rZ/'!'~j_.'.~_ Tank size o, ~.o Other bacteria Collected by: 17034 F~a..31e P4'~r Loop Read No, 204 /(/'2~O g~/---- Compartments Cleanouts~) High water alarm. (Y~ Date of pumping _ ?/~ / Foundation cleanout(~) ~/'~' Depression (Y~ Alarm tested (Y/N) ///~ pumper ,~ ~'/L°~:~- 5(:5 SEPARATION DISTANCES FROM SEPTIC/~ TANK TO: Well(s) on lot /'g6~ t~- __On adjacent lots /~)~ /'''/'-- To property line /O [ ?~ Abs(~rption field Surface water/drainage 72-026 (3/93}* Front Foundation ~(~ Water main/service line CONTINUED ON BACK PAGE .Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DIST~:,~U>E~ROM LIFT STATION TO: _.~.~~ On adjacent lots D. ABSORPTION FIELD DATA Date installed Length 4~'t Width Total absorption area ~ _~-'d_3 zz~ sent(~/ Cleanout pre N) Date of ade.uacy test /O/Z.~/¢ 3 Resu,t~p~a.>"~-~ Water level in absorption field before test //2 "~'~ Peroxide treatment (past 12 months) (Y,~.. Manufacturer _Manhole/Access (Y/N)_..~'~''~''~ ~ 'Pump on" level at~'"'"----~_ ~ff" Level at ~ted Soil rating (GPD/Ft2) //2--¢' ~"~/~'/~ System type Gravel thickness ~ ~ Total depth ~ Depression over field (~ ~ ~ ~ fo~ T~ ~ ~ ~d~oom~ After test ~ /r If yes, give date ~ Property line /(:~ / SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot //~L~ [~/'-- On adjacent lots /~-)L3 ('-7¢~ Driveway, parking/vehicle storage area To existing or abandoned system on lot .,~'~/L/C-C-' //--/5/t-/~'' ,/?{.¢Ld/¢~ater main/service line To building foundation On adjacent lots ~.O ~ Cutbank Surface water r/~___PC3 Curtain drain ,,L-/L~,'~'~'- E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on ~ S,gnatur~ ~'~,N~..,NO Engineers Na~?n~ ~v~ L;~¢, ~',.~ ~'~. 2~ Da ts ~ver, AI asea ~9577 ;~ ~ HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number this inspection. 72-026 (3/93)* Back 11~01/D~ ~5:4~ CT&E ENU!RONMENTAL LAB SERU!CES N0.540 Q06 COMMBRCIALTESTII%I~3 & ENG~N~=~=R{NG CO= ENVIRONMENTAl_ LABORATORY ~ERVICE$ ,~,,c:~ ,~o.. REPORT of ANALYSIS Chemlab Ref.~ ;93.5722-9 Client Sample ID ~L~4 B2 SUNDi LAKE 6/0 Matt ix : WAT~ 6635 B STREET ANCHORAGE, AK 9~518 TEL:(90~ 562-2~43 FAX:{90~ 56~-5301 Client Naive :$ & Ordered By ' .~C~, ~ :10/~5/93 7~ ~. PWS!D : UA - z ' ' 20 Technic~ ~ L].~ r. ect oF; STEPHE ........................ . ......................... / ? ~{/~ ~"~ Q'C AilowaDle E×t. Anal F'srameter o ,- ~ Nitrate...N 0.10 U mg/L [,.:PA 353.2/;,,::~ .) 10 10/28 LLH See Special i~$tructions Above UA = Unavailable see Sa~,~pJ.e Reread.ks Above NA = Not An~!yzed U~detected, Reported vsl~e is the pr~cticai quar~.ific~ttc~-, lb~t. LT = Ce~s Than Secondary dilution. GT ,~ Greater Than ~ (a) ,Eega Descr pt on ( nc ude subdMsion : : Lo~; 14 B~ock~2~sundi Lake Subd:i'; :; :'[~?:!!~: lc ;: Applicant is'(che~k one: ~nding Institu[i°n B } owne~}~iider~i BUyer ,,;, {d) Lending Institution ': ' Address 1000 R. Dlmond, Real Estate Co~ Suite 100,;Anchorage AK. 99515 "ATTN..PaSricia Hunter: ¢ :,i (f)Ma!l,the:HA~ to the following add(ess: Note: If commvnity well system, must have written confirmation,from the State Department of Environmental Conservation attesting to th legality and status~ : ;;~ i to t ~ tegality and status. ,;Page 1 of 2 · -~?, EN~I~E'RI~ ~IRM'~i~ING I~S~ION~, :TESTS, FIlE SEARCH; DATA AND INFORMATION ~ As cedified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval 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 fudher verify that based on the information obtained from the,Municipalityrof Anchorage files and from my investigation and inspection, the on-site w~PnlY and/~ ~; ~ ~a~t~W~{~?iSposa S~{~m i~n complia~,e With ~il ~unicipal and State codes, ordinanceS, and regu.....~....- ~ ' effect o... : ;Ad~es~. 11600 Canoe Road,:~A~chora~e ~K'~ 99516 '~ Da(e "??7/2/86~. ;:' ~:~ ~, ",~. .... :~ ' ~:EngineerS'SeaJ - , i: :;:: : ~:Termsof Condtona Approve ::: .' : :. : , .:.,: :: : ;;: engineer ?e~iStered j:~;il~ state of AlaSka;' The DHEP d0b~ thiS'a~ a cOurtesy to pUrchaserS o~ homes and thei~ ler~di~n institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data bef0r~'~:~ertificate is issbed,;The MbnidiPality of Anchorage is not responsible for errors or omissions in the ~:' ~0fessl0nal enginebr's : WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) tVgJN[C[pALITY OF Ai-~E...,~ AUTHORITY APPROVAL (HAA) DEPT OF HEALTHN~ - .... ~,-TC.o~ECKLIST - FEBRUARY 1984 ENVIP.©HMENTAL ~ 264-4720 ~" ~!_ © Legal Description: RECEIVED Well Classification ¢'~'~"4'¢¢1''~'- If A, B, C, D.E.O..Approved (Y/N) ~'~ Well Log Present (Y/N) ~ Date Complete~ f~,['7 / ~;;~ Yield Total Depth ~'~-'~ Casedto Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Pump Set At Cf'~s,vw~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~-'~/' · On Adjoining Lots To Nearest Public Sewer Line ~ J J~ TO Nearest Public Sewer Cleanout/Manhole ~ ~ ~ To Nearest Sewer Service Line o~ Lot ~ ' J Water Sample Colleoted by ..'~..J,,4~:~,~,~ ~6r. _'~'_ ..~_.~1~¢_ ;Date ~'~!J Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed "7. fJ ~:~/~ Size ~ ~::~ ~' No. of Compartments Standpipes (Y/N) ~*"~ Air-tight Caps (Y/N) '~"~%, Foundation Cleanout (Y/N) ~.~, Depression over Tank (Y/N) I~::~ Date Last Pumped ~'~/I/~ ~ Pumping/Maintenance Contract on File (Y/N) ~ [ ~ ;for ~ ! '~ Holding Tank High-Water Alarm (Y/N) t~( ~. Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: TO Water-Supply Well :r ~" To Building Foundation To Property Line 4' ' To Water Main/Service Line ( ~q~'t~rf ~'~:~' ~ ~' ~( Pond, Lake, or Major Drainage Co.rse Comments Page 1 of 2 72 026(11/84) 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 ~ ~'~4" / TO Property Lin~ 4'~ / Type of System Design Length of Field ~/~,,~ / Depth of Field ! -Z./' Gravel Bed Thickness ~_'~ 'F-~-~E~ Standpipes Present (Y/N) Date of Last Adequacy Test To Building Foundation __ Lot ~.4~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Existing or Abandoned System on ; On Adjoining Lots ~'" I'*lc- TO Cutbank (if present) t5 ("~f'-' 'T~ Z 2 ) S~f'%¢' To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Dimensions Size in Gallons --%nhole/Acc~./N) "Pump On" Level at ~ 'lPump Off, LeVel at High Water Alarm Level at / '~ ) Vent(Y/N) Tested for / '~ / Pu mping~¢es~during Adequacy Test. Meets MOA Comments/ ~ ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I bave c~hecked, ve~ conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed "~"'"~. [.4'ov.. ¢,,~ Date Company IAJ, J~_ 4~J~.~..,~.~ No. Date of Payment Amount: $ ~% .~ ~-4~}~~~¢ Engineer's Seal DATE RECEIVED INSPECTION APPOINTMENTS MUNICIPALITY OF ANCHORAGE DEPT, OF H~ALTH &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~vjRONMENTAL PROTECTION ~ ~ 825 L Street - Anchorage, Alaska 99501 { E.WRO.UE.T*L S*.~TAT~O. D~WS~O. OCT 2 9 ~980 Telephone 264-4720 DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proce~ed. Please allow ten (10} days fo~ processing. PROPERTY RESIDENT (If different from above) PHONE 4. REALTOR/AGENT MAILING ADDRESS 5. LEGAL DESCRIPTION Low IZ/ , STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF~SEDROOMS ~ [] One [] Four [] Other SINGLE FAMILY [] Two [] Five MULTIPLE FAMILY ~ Three [] Six 7. WATER SUPPLY /~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTI LITY depth (attach log if available,) 8. SEWAGE DISPOSAL SYSTEM ,NO,V,DUAL ON-S,TE** YE^B ON-S,TE SYSTEM WAS,NST^LLED. [] PUBLIC UTI LITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 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 31 SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] iNDIVIDUAL/ON -SITE DATE INSTALLED []PUBUC UTlUTY Connection Verified NSTALLER []Septic Tank or [] Holding Tank Size:_I~)(~(::~ If Tank is homemade SOILS RATING give dimensions: TOTAL ABSORPTION AREA MATERIAL Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line 4. DISTANCES WELLTO: 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)