HomeMy WebLinkAboutT15N R2W SEC 25 LT 27
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PID:051-281-24 PERMIT:OSP241182
FIRST WATER CONSULTING
T15N R2W SEC 25 LOT 27
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP241182 Effective Date:
Work Type: SepticTank Upgrade Expiration Date:
Tax Code Number: 05128124000
Site Legal Address: T15N R2W SEC 25 LT 27 G:0753
Site Mailing Address: 18029 KAMKOFF AVE, Eagle River
Owner: ERICKSON PAUL B & MARY H Lot Size in Sq Ft:
Design Engineer: FIRST WATER CONSULTING Total Bedrooms:
This permit is for the construction of:
7/19/2024
7/19/2025
108900
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: 15.E - F tv, L Date:
Issued By: � Date:
3
ON -SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051-281-24
Property owner(s) Paul & Mary Erickson
Mailing address PO Box 771744 Eagle River, AK 99577
Site address 18029 Kamkoff Avenue Eagle River, AK 99577
Legal description (Sub'd., Block & Lot)
Day phone
Legal description (Township, Range & Section) T1 5N R2W SEC 25 LOT 27
Lot Size 108,900 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(S all that apply)
Absorption Field
❑
Initial El
Single Family (SF) ER
(w/wo ADU)
Septic Tank
ER
Upgrade Gi
Duplex (D) ❑
Holding Tank
❑
Renewal ❑
Multiple Dwellings 0
Privy
El
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION
INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicabie. Mni&pal. Codes.
(Sig natu.re- of.prqperty�qwne'r_or authorized agent)
Permit/Rush Fees:2 Z Waiver Fees:
Date of Payment: 61--771Z-Y Date of Payment:
Receipt Number: Lt 1 3 Receipt Number:
Permit No. O5P2 9 J J S-L Waiver No.
GAIDevelopment Services\Building Safety\On Site Water and Wastewatefforms\Client FormsTermit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / FirstWaterAK@gmail.com
!
!!
July 2, 2024
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: T15N R2W SEC 25 LOT 27 (18029 KAMKOFF AVENUE, EAGLE RIVER)
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank on the above referenced lot. We propose to install a 1000-gallon deep burial HDPE tank
per the attached design to serve the existing 3 -bedroom residence. A 1500-gallon septic tank
may be considered for current functionality and future consideration or flexibility.
Groundwater was noted in the MOA on-site file and is not anticipated to affect the septic tank
installation. If groundwater is encountered during installation that may affect this septic tank
upgrade, an epoxy coated steel septic tank or other action may be required.
The lot and area are served by private water and any encroaching wells, easements, … must be
staked prior to construction. The design will not impact any of the neighboring properties.
Please contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241182, Curtis Townsend, 07/19/24
FIRST WATER CONSULTING
T15N R2W SEC 25 LOT 27
DESIGN DETAILS:
NO WELLS WITHIN
100' OF PROPOSED
SEPTIC TANK
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241182, Curtis Townsend, 07/19/24
Municipality of Anchorage Page
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
Permit Number: ~/- ~/~'~ PID Number: ~_'6'~,/~-~,~/~,/-/
Name: Wastewater Syslem: .~New [] Upgrade
Address:
FIELD
Phone: IN°'°f'~Bedr°°ms: [] Deep Trench [] Shallow Trench ~Bed [] Mound [] Other
LEGAL DESCRIPTION soi, Rating: O, r GPD/Sq. Ft. ' Total Depth~ · ~ from/origrnar grade:
Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township: J Range: J Section: Fill added above original grade:, Gravel length:
Classification (Private, A,B,C): Total Depth: Cased TO; Total absorption area: Pipe material:
Driller: Date Drilled: Static Water Level: Installer: Date installed:
Yield: GPM IPump Set at: Ft. JCasmg HeightAbove Ground:Ft. TANK
SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P.
To Septic Absorption Lilt Holding P~Privat( Manufacturer: Capacityin gallons:
Material: Number o~ Compartments:
s~f~ ~ LIFT STATION
Water ~ ~ ~]~ ~ ~
Lot/ Size In gallons:~ Manufacturer:
I
Remarks: ~s~ ~ ~*~,~ ~ BENCH MARK
Inspections performed by: ~* J Dates: 1st ~/~/~
Department of Healt d n Serv. s approval %00
Reviewed and approved by: ate: ¢~/ ~x,~
72~J13 (1/91) MOA 25
PermJtNo. 9'/-~o/,-/o 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:
/ %
72~]13 A (2/gl) MOA 25
PAGE
1 OF
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW910140
DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC.
OWNER NAME:MORRIS, MOLLY B 50% &
OWNER ADDRESS:3515 W. 42ND AVENUE, UNIT A
ANCHORAGE, ALASKA 99504
PARCEL ID:05128124
LEGAL DESCRIPTION: T15N R2W SEC 25 LT 27
LOT SIZE: 108900 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
DATE ISSUED: 6/07/91
EXPIRATION DATE: 6/07/92
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
1
SPECIAL PROVISIONS:
1. EXISTING PRIVY MUST BE ABANDONED PRIOR TO FINAL
APPROVAL.
2. POST TANK CLEANOUTS MUST ENABLE CLEANING OF ENTIRE
LINE BETWEEN TANK AND FIELD. ADJUST CLEANOUT LOCATION
AS NEEDED DURING INSTALLATION.
3. MAXIMUM INSTALL~T.H IS 5.0'.
RECEIVED BY:
DATE:
DATE:
PROPOSED SEPTIC SYSTEM DETAILS
ABSORPTION AREA CALCULATIONS: 3 Bedroom X 150gpd/bedroom = 450 sf
Soils rating: 0.8 gpd/Df (Bed)
450 sf / 0.8 gpd/sf = 562.5 sf required surface area
Use Bed with 15'w x 40'1 for 600 sf surface area.
IMPACT ON ADJACENT LOTS: There is no adverse impact on any adjacent lots with
these proposed improvements. The existing lots, except for Lot 9B, Madeline
Subdivision, each have full improvements in place, and Lot 27's development
will not restrict Lot 9's future development.
SITE PLAN DETAILS--PROPOSED ABSORPTION SYSTEM
NE1/4 SEC 25, T15N, R2W (BIRCHWOOD)
LOT
27
PREPARED FOR: MOLLY MORRIS
3515 W 42ND AVE, UNIT A
ANCHORAGE, AK, 99517
NOT TO SCALE DRAUN BY CAL
CONSTRUCTING ENGINEERS
9601 BUDDY WERNER DR
ANCHORAGE, AK, 99516
3&6-2000
69~--9098
DRAWING # 91-S2-05-4
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE P ER FOI),I~
Township, Range, Section:/'J~ ~/'F .,~7..,'~ -ri 5"/k.~ I'Z 'Z.~
1
2
3
4
5
6
7
8
10-
11
13-
14-
15-
16-
17
18
19
2O
COMMENTS ~'~'
SLOPE
WAS GROUND WATER ~.-~.
ENCOUNTERED?
S
IF YES, AT WHAT ~_. OL
DEPTH? p
E
Depth to Water After
Monitoring?
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
~ ~/~/,~, ¥ ¥ o" --
,~ ~,,~. ', i o~{~,''
:' I ~ " ~o ~//~'' I;"
PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER JO//
TEST RUN BETWEEN ~ FT AND ~ FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72~008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: s/~/~ ~
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
DATE PERFORMED:
Township, Range, Section: ~= ~
1
2
3
4
5
6
7
8
9
10-
11
13-
14-
15-
16-
17-
18-
19-
20-
COMMENTS
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
·
IF YES, AT WHAT
DEPTH?
Depth to Walor After ~
Monitoring? Dale: ~'-~-~t
Gross Net Depth to Net
Reading Date Time Time Water Drop
, /ztg, o - -
~ ~ ~ I ~ '~'/~ I ~/~"
PERCOLATION RATE __
(minutes/inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN FT AND FT
~-¢- o,~ ?p~/r~c ~ .-~,-~-,~_~.4,~,~
PERFORMED BY: ~T~'~, ~1- ~'~)1~'I~1 ~ CERTIFY THA~ THIS TEST WAS PERFORMED IN
ACCORDANCEWITHALLSTATEANDMUNICIDALGUlDELINESINEFFECTONTHISDATE. DATE: ~/~/91
72-008 (Rev. 4185) %~T ~L~ ~ ~
Tom Fink,
Mayor
] unicipality of Anchorage
Department of Health and Human Services
825 "L" Street
P,O. Box 195650 Anchorage, Alaska 99519-6650
August 6, 1991
Building Safety
Department of Public Works
3500 E. Tudor Rd.
Re: Lot 27, Sec.25, T15N, R2W, SM
Dear Sirs:
Please be advised that DHHS will not require a permit be
issued for the existing well on the above referenced property.
The well was constructed in the mid-sixties and as there exists
no available well log and S&S Engineering confirms the wells
integrity and water quality no permit is necessary.
Should you need clairification please contact our office at
ext. 4744.
Daniel N. Bolles
On-site Services
ROBERT SHAFER, P.E.
ROGER SHAFER
mmm~eINVOICEmeeme
CIVIL ENGINEERS
(907) 6~4-2979
FAX 694-1211
TIN #9~-0105405
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
4MOUNT
WELL INSPECTION
& FLOW TEST
, SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESfGN
TO~AL
TERMS ARE DUE ON RECEIPT
C~IARGES OF 1.5% AFTER 60 DAYS
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (90~ 561-5301
Date Report Pxlnted: JUL 22 91 ~ £1;$8
Chert% Sample ID;L27 SEC 25 T15N R2W Client Name
?WSID :UA Client Acct
Coils:ted JUL 17 ~I ~ 17:30 nra, DPO $
Eecoayed 3UL 18 91 ~ i4:09 k~s. [eq J
?[eservad with :AS REQUIRED Ordered By ;R. S~AFER
lnalyais Ccmpleted :JUL i9 9i Sand Rspo:ts to:
R~leased 5y : __~ ~
Chef, ab Her ~: 913491 Lab Smpl !D: ! ~h%rix: WATEH
Miowable
['.~ram~t ez Tested Result Ur~t~ J~et hod L:~ts
...............................................................................................................
Sample RGUTIN'E SAMPLE COLLECTED ~Y: RAY
I Tests Performed ' See Specaa] instxuctlorm Above UA-Unavailable
~{D- None Detected "See Sample Remarks Above
NA- Not Analyzed LT-Les, Than, CT-Greater Than
~SGS Member of the SGS Group {Soci~t8 G~n~rale de Surveillance)
CLOCK
TIME
' 17034 £"gle River Loop Road FIORERT &, 8flAFEfl
PflOJEGT: ~~ ~ ~
LOGATION OF WELL (Le,~I Description}: ~ ~ ~
WELL DEPTH:, ~ ~ FT. CASING: ~
DATE DRILt. ING COMPLETED: _._._
8TATIO WATER LEVEL (Top Of Cl$1ng): ~ '~"E~~
ELAPSED TIME SINCE
PUMPING STARTED/
STOPPED, MIN.
· 0
4l)
45
DEPTH TO
WATER,
PT. DAm_ -1-:i'~ -~ ~
DRAWDOWHI
RECOVERY
PUMPING
RATEiGPM
REMARK8
I 0
· $
Comment,~:
Flow is not Guaranteed
Subsecluent Variations
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COSA Checklist.docx
COSA Checklist
Legal Description: T15N R2W SEC 25 LOT 27 Parcel ID: 051-281-24
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled UNKNOWN Total depth UNK ft
Cased to UNKNOWN ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 6/18/24
Static water level at beginning of test 60 ft.
Well production at time of test 3 gpm
Water storage tank volume NONE gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 2.24 mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by Date 6/18/24
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank NEW
Date of pumping NA
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 8/28/91
ALL standpipes present per record drawing
Total measured depth from grade 4.8 ft (max)
Measured depth to pipe invert from grade 4.3 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective. (ED)
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 6/18/24
Results Pass
Fluid depth prior to test 0 in
Water added 450 gal
New fluid depth 1 in
Elapsed time <30 min
Final fluid depth 0 in
Absorption rate 450 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 6 in (MOA 0.5’ ED)
Effective depth used 0 in (Final Fluid Depth)
Effective depth (ED) remaining 6 in
Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots &
appears approximate.
COSA Checklist.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 8/16/24
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
8/16/24
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot 27, Se~ion 25, TI5N, ~ S.M.
Location (site address or directions)
18029 Kamkoff
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Paul EricSson
Day phone
P.O.Box 771744 Eagle Rive~, Alaska 99577
CITY ~ORTGAGE ATTN: ~=~a;~n~ Day phone
Ea.qle Riv~r~ Alaska 99577
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well XX
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:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State AD£C
attesting to the legality and status of system.
72-025 (Rev. 1/94) Fron~ MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown be[ow, 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.
Name of Firm
S & S ENGINEEEING
Address 17034 Eagle River Lool3
Ea,31e Rivar, Alaska
Engineer's signature
Phone
o
D..S S,G.*T..E
Approved for bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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. 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.
(~ Municipality of Anchorage
Department. of Health & Human Services
HEALTH AUTHORITy APPROVAL CHECKLIST
Legal Description: ~>'('~-/J, 5~('~'~"~\~''}'-~', ~"~'~-~ Parcel ,.D; /~,~-/;-A~
A1 WELL DATA
Well type ~l~'~J
Log present (Y,~
Total depth L~/L-
Sanitary seal ~.Y)/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed O~--- Driller
Cased to ~i'C)~ ¥ Casing height
Wires properly protected ~N) "'/
Date of te§t
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
AT INSPECTION
MUNICIPALITY OF ANCHOP. AG~
ENViP, ONMF-NTAL SERVtCE,S DIVISION
JUI. 2 2 1992
L~ ,~ ' g.p.m.
/ e t' .RECEIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line ~-~'~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petrbieum tank
WATER SAMPLE RESULTS:
Coliform (~ ~'~'J~o~. ~.. Nitrate
Date of sample: ~ .-- ~ L~ -~'Z~
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~ . Z. 8 -'~ I Tank size / o6o
Other bacteria ~
S & S ENGINEERING
17034 Eagle River Leap Road NO. 204
Eagle River, Alaska 99577
Compartments
Cleanouts~'N) ? Foundation cleanout~N) ~ Depression (Y~
High water alarm (Y{~I./g /'~ '
Alarm tested (Y/N):
)~..EDate of pumping $ ,~. ~- '~ Pumper. _
PARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
~-
Foundation
Well(s) on lot ~,/->~' ~ ¥ On adjacent lots ~c~
To propertyline lc> AbsorPtion field lJ'c:>~
t~
Surface water/drainage I ,.~ ~
- Water maih?service line \ c,
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electdc~
SEPARAT~ONd~FSTANCE FROM LIFT STATION TO:
~N~II on lot On adjacent lots
Manhole/Access (Y/N)
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ~'?-"~' ~°t
Length ~'0 ~ Width
Total absorption area
Depression over field (/'~r~)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y~J~/
Soil rating 0,,5 .f~ System type r~l,,,~
Gravel thickness ¢', ~- Total depth
Cleanouts present ~/N)
Date of adequacy test
for '4/4. bedrooms
¢"~ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot I
To building foundation
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERT'IFICATION
On adjacent lots ~c:,o ~4r Property line
Lcc~ ~ . To existing or abandoned system on lot
Cutbank ~--~//~- Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
Signature
Engineer's Name
Date
S & S ENGINEERING
17034 Eagle River Loop Roa~
Eagle River, Alaska
HAAFee$ /~0
Date of Payment ~,7.
Receipt Number ~ ~ '~/"~
72~026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number