HomeMy WebLinkAboutHIGHLAND HILLS #4 BLK 2 LT 23Highland Hill
lock 2
Lot 23
050- 382
-57
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program, 4700 Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page 1 of 3
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: OSPl11251 PID Number: 050-382-57
Name:
James & Nora Labelle Wastewater System: [] New [] Upgrade
Address:
5427 Wild Mountain Drive ABSORPTION FIELD
Phone: Number of Bedrooms:
;~ [] Deep Trench [] Shallow Trench [] Bed [] Mound [] Other:
LEGAL DESCRIPTION soil Rating: Total Depth from originalgrade:
1.2 GPO~Ft2 10 Ft.
Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe:
2 23 Highland Hills #4 4 Ft. § Ft.
Township: Range: Section: Fill added above original grade: Gravel Length:
0
Well: [] New [] Upgrade Gravelwidth: Number of lines: I Distance betweenlines:
2.5
I
Classification (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material:
Existing Private Ft. Ft. 384 Ft2 3034 PVC
Driller: Date Ddlled: Static Water Level:Installer: Date Installed:
Ft. A+ Home Services 10/512011
Yield: I Pump Set at: Casing Height Above Ground:
GPMI Ft. Pt. TANK
SEPARATION DISTANCES [] Septic [] Holding [] S.T.E.P. [] Other:
T~To Septic Absorption Lift Holding 3ublic/Private ' Manufacturer: Capacity:
From~
Tank Field Station Tank Sewer Line Anchorage Tank 1000 Ga~.
Material: Number of Compartments:
We, 105.4 112.7 25+ Steel 2
Surface Water100+ 100+ ~ / LIFT STATION
Lot Lina 24.5 12.7~ Size: Man~acturer:
Gal.
Foundation 47.7 63.5 "Pump on' ,eva, at: "Pump oW' ,evel at: I ,igh w~ter alarm at:
in.in.I in.
Curtain Drain N/A NIA Pump Make & Model Electrical Inspections performed by:
Remarks:
BENCH MARK
Location and Description:
Spike in Tree
Assumed Elevation:
100.0 Ft.
Engineer's Stamp
Inspections performed by: PANNONE ENG. SVC, LLC Dates: 1st 10/5/2011
Development Services Department Approval
Conditional Approval Date:
~.Steven FR. Pannone/~.
Reviewed and approved by: /) ate: /L~ -/3
/\ / / x~.~ r~' , ,
/ / \ EXISTING SEPTIC r / ~ ~_:., A~L~SATING SEPTIC
EW 1 O00g SEPTIC TANK 't. ",,
INSTALLED DCO BEFORE AND A~ER TANK ~ .......
NEW DRAIN FIELD ~:: ~ ....... ',, , / /'~/'/
,52 LF x 6' ED x 5'W ~ 10' TD ~ / '~
... ,,. .~ ~ .~ . ........ ~ ~ '. ~. /..~././
/
~ x. ' . ..... ~ t.:t ;.~ :.:, . .....
~ .,,:. , ~ > ~ A G"
~' 1127 ' ' ~
/
'"~'~ 1~ ~ /.,.'"" /,~" XISTING LINE ',.,. '"'., ", :
Z ~ ~ " ~, /'" //' "* '""
~ ~ ~ ~.~.. '~.,.. ~.. ~'r. '.., '.~ '.......,. A B
~ ~ / '~. ". ",. t. '",, ". ',. '~',, DC1 43.8 57.7
~ b ' / '",, '".. ",, '"' "~.. '",, "'", ' ....... T1 49.5 62.5
~ '" ":'. '" '"'. '"~ ~, '"'. T2 55.0 66.5
WZ~¢~~ '" '"" '"" ..... " " M1C1 7171.8'5 66.565'0
C2 67.9 77.6
M2 68.5 76.9
~ ~ _, ,~ Date
~o,~: P~O~ ~G ~C, ~ .
RECORD DRAWING p.o. BOX 100217 ANCHORAGE, AK 99510
l~~ .....L ~ lO/7/11
PHONE (907) 272-8218 F~X (907) 272-8211 ~.-
~... ~ ~ ~ ...,~ ~"=~o'
HIGHLAND HILLS ~4, BLOCK 2, LOT 25 ~ ~ ~.LD. NO
JAMES ~ NORA LABELLE ~'. CE 8149 '~ PERMIT NO.
5427 WILD MOUNTAIN DRIVE ~ii~'ill~ll .~ 0SPl11261
PLAN EAGLE RIVER, AK 99577 ~ " ...... ' sh~t
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION WAS INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE
STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON-SITE
WASTEWATER DISPOSAL SYSTEMS.
2. ALL WORK WAS IN ACCORDANCE WITH THE ATTACHED SPECIFICATIONS.
,3. SCOPE OF WORK: INSTALLED NEW SEPTIC TANK AND SOIL ABSORPTION SYSTEM.
4. NO GROUNDWATER WAS OBSERVED AS EVIDENCED BY THE SOIL TEST HOLE. AN APPARENT WATER TABLE WAS NOT
OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 1 6 FEET BELOW EXISTING GRADE.
/,,,-FILTER FABRIC
SP/ 4.01 ~ /' ~__L 05
~ ~'~GRAVEL BEDDING
6.0 ~!'~ ~-4" ¢ DRAIN PIPE
F- 86 5 -- GRAVEL
-~ 80.5 2 SECTION
No groundwater
monitored
~o
¢0 0 0 g~ d ~ F810 HDPE
'-98.0- ~ _~~~_
SEPT, C TANK 92'5/ ~
86.5-- ; ~ --86.5
DESIGN PARAMETERS LEGEND
PRIMARY SEPTIO SYSTEM
NO. BEDROOM: 3 (450 gpd) ~W-~ WATER LINE/ ABBREVIATIONS
TANK SIZE: lO00g WELL RADIUS CU OOPPER
PERO RATE = 1-5 MPI DIP DUOTILE IRON PIPE
SOIL RATING: 1.2 GPD/SF ~ 88 ~ NEW SEPTIO TH TEST HOLE
AREA RQD: 575 SF FC FOUNDATION CLEAN OUT
SYS. ~PE: DEEP TRENOH 6.0' E.D. T~ TANK CLEAN OUT NO.
MIN LENGTH: 31.3 LF O~ CLEAN OUT NO.
USED: M~ MONITOR TUBE NO.
52 LF X 2.5' WIDE, 6' E.D., R.I. RIGID INSU~TION
10' TD DO0 DOUBLE CLEAN OUT
TOTAL AR~: 384 SF DV DIVERTER VALVE
FS FLOW SPLICER
RECORD DRAWING p.o. BOX 100217 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211 ~.- ~:~ Sc=~e
JAMES & NORA LABELLE rCa~-. CE 8149 '2~ PERMIT NO.
5427 WILD MOUNTAIN DRIVE ,ll¢Alll¢l{ ,~%~ 0SPl11261
Permit Number:
Tax Code Number:
Work Type:
On-Site Wastewater Disposal System Permit
OSPl11261
05038257000
Septic
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 EImore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Upgrade
Permit Effective Dates: September 28, 2011 to September 27, 2012
Design Engineer: PANNONE ENGINEERING SERVICE
Subdivision: HIGHLAND HILLS #4
Site Legal Address: HIGHLAND HILLS #4 BLK 2 LT 23 G:0558
Owner/Address: PANNONE ENGINEERING SERVICE
PO BOX 100217 ANCHORAGE AK 99510
Site Mailing Address: 5427 WILD MOUNTAIN DR, Eagle River
Lot Size in Sq Ft: 104378
Total Bedrooms: 3
This permit is for the construction of:
Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage
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 wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By: "~3/
Date:
Date:
~"'?, Munic a of Anchorage ~,~~.
P.O. Box 196650 · 4700 Elmore Road ~: >>
~ Anchoraqe, Alaska 99519-6650 ® (907) 343-7904 · Fax (907) 343-7997 Department
http:llwww.muni.orqlOnsite
Development Services Department
On-Site Water and Wastewater Program
**** VARIANCE/WAIVER REVIEW ****
Waived¢: OSPl11271 COSA#: ~ Permit~: OSPl11261
PID#: 050-382-57
Legal Description: Highland Hills #4 Block 2 Lot 23
Engineer: PES
Applicant: James and Nora Labelle
Your request for a waiver of the required 50 feet horizontal separation from the absorption field
to the excessive slope has been approved. The approved separation distance is 8.0 feet.
This waiver approval applies to the existing absorption field only. Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
Waiver is Granted: X Waiver is not Granted:
Date:
Name of Reviewer
Rec#: Amount:/~///-~ Date Paid:
'-T--
**** VARIANCE/VVAIVER REVIEW ****
I UNICIPALITY
Community Development Department
Development Services Division
On-Site Water & Wastewater Program
Mayor Dan Sullivan
OF ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D.Or;-,~-'O- .~-'-~'~
Property owner(s) '~0'¢"~E-5 ,~-- ~e~ ~~ Day phone
Mailing address ~-~_~ '~)i~ ~:~o~T~~ ~t ~, ~
Site address ~"Z 7 ~ .4(~/T~l~J ~ ¢ L~
Legal description (Sub'd., Block & Lot) Hll-I~L~¢ HI~¢:?
Legal description (Township, Range & Section)
Lot Size i0~2:~¢ Sq. Ft. Number of Bedrooms
THIS APPLICATION IS FOR: THIS APPLICATION IS AN:
([~ all that apply)
Initial
Absorption Field ~
Septic Tank ~. Upgrade ~
Holding Tank [] Renewal []
Privy []
Private Well []
Water Storage []
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
I certify that the above information is correct. I further certify that this application is being made
for a Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of p p r~y owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
Permit No.~. ,_.., ~' ';
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
G:\Building\On Site\Forms\Client Forms\Permit App_010411 .doc (Rev. 1/11 )
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail: steve@panengak.com
September 28, 2011
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
4700 S. Bragaw Street
P. O. Box 196650
Anchorage, Alaska 99519
Subject:
Highland Hills #4, Block 2, Lot 23
Septic System Permit Upgrade Request
Ladies and Gentlemen:
I am writing to request a permit to construct an upgraded septic system be issued for this property. The
proposed system will serve an existing three-bedroom house. Currently the lot is developed. The lot is
served by a private well. The existing drain field is in failure and shall be re-used as a reserve at a later date.
A new drain field will be installed west of the existing field and will be sized to handle a three-bedroom
waste stream. The surrounding developed lots are served by private wells. The private wells are located
over 100 feet from the proposed soil absorption system.
1. Soils. One test hole was excavated by Pannone Engineering Service in September of2011. See the
soil log attached. Ground water was monitored for seven days. No ground water was monitored to a depth
of sixteen feet (16') below ground level after the monitoring period. Bedrock was not encountered in the test
hole. It is my opinion, based on the results of the percolation tests and overall soils appearance; an
application rate of 1.2 gallons/day/square feet should be used, using a conventional wastewater treatment
system.
o
Soil Absorption System Design.
a. See Sheet 2 of the design package
3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and the
existing drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water
and drainage ditches.
4. Topography: The average topography in the area of the proposed septic system is approximately 15.
percent based on the survey information in the area of the septic system. There are no steep slopes within the
vicinity of the proposed drain field.
I",/aiiins: ?,O, [~ox 200227,, Anchorage, Ai-(
?hysicai: 61,5 East 82~'x'~ A~e, Cuite B6, Ancho:a6e
l'eleN, hosse: (907) 272--8218 FAX: (907} 272-8225
Page 2 of 2
5. Slope Waiver: I would like to request a slope waiver for the existing field. It is currently in failure
and will not be connected to the new septic tank. The field will be left in placed and decommissioned to be
reused at a later date. The edge of the field is located approximately eight feet (8') from the edge ora steep
bank having a 100 percent slope. The system was installed in 1978 and has worked adequately until this
year. Effluent has never been seen day-lighting over the edge of the slope in this time. Currently the system
is in failure with water levels a foot below the ground surface. The slope was inspected and there was no
evidence of day-lighting of sewage. This system has been in operation for 33 years and even in a failed state,
has shown no signs of effluent day-lighting over the edge of the steep slope. I therefore request a waiver be
granted for this system for its future use when the upgrade system needs to be replaced.
6. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification
that the review is complete and that there are no further comments is received from MoA On-Site
Department, the note will be removed and "Issued for Construction" drawings will be issued.
The proposed installation will not affect the future development of the surrounding or existing lots. There
are no wells within 100 feet of the proposed septic location.
If you have any questions or concerns, please contact me at 272-8218.
Sincerely,
Steven R. Pannone, P.E.
Owner/Civil Engineer
Attachments:
Mai in~N P~O~ Box 1002i7~ Anchol~a8% AK 99510-02i?
~'}' ~'; ..... ~ 615 82m~
~ ,~,~:,,-~,~ .... PigS{ '""~ ~"
......... ~.~ Suite g6~ ~ ...... ;' ..... ' ....... AK
AREA
. -.. ,..:" ' ·
l O00g SEPTIC TANK (P)~ i' .. 7/'
INSTALL DCO BEFORE AND AFI-ER TANK ':-1 " ' , -.~,/'" /
~ ~ " .'~' , 'xl ........ ' ' '"" ·"
DRAIN FIELD (P):~ ~< ,., :. ~ '/.' ,,,
,52 LF x 6' ED x 5'W x 10' TD ~ ~ ...................... , ' ,...," "~.' ',,"
~::: :' ':~ ' :' S :No DRA N FIELD
~ N~ ~.' ~ IN FAILURE TO BE ABANDONED
// ", ',i/'??j~-M~~ /, X ~IN P~CEAND RE-USED IN THE
4~ ~:::'")'~~~N~~'a .' FUTURE. SEE LE~ER.. ,
/ '"- , /"/,~ ~~"~ N ~ ABANDON'ExIsTING
/ .... ::'., x~ ~c/ ~~ ~ ~, ~ 1250g SEPTIO TANK PER CODE
/ /. ~ .,~.~~ ~ Nx .,,.. ,,
/ ~ > / / ,' ~,,.' ~?~ / ~ OVER PIPE ~ UNDER DRIVEWAY
~ , , . ~,. · ..-,` ..
~ Z~VV//,. ' ,." ... '. . · . , ..
~ . .. , . ~ ',,, ,., , ,
~~ Da te
.OTIS: P~O~ ~G ~C, ~ -.~-' oF AL-'~,'" ~/~/11
FOR CONSTRUCTION P.O. BOX 100217 ANCHORAGE, AK 99510 ~".. .... · ~..~'~j
N...'~ ~_.'...~ ~"=~o'
HIGHLAND HILLS ~4, BLOCK 2, LOT 25 05o-~82-s7
~ ra gteven R. Panno~e ~
dAMES ~ NORA LABELLE rli~'. CE 8~¢9 -~ :ERMIT NO.
~27 W~LD MOUNTAIN DRIVE ~i;~Z.. .~ OSml~
PLAN ~A~L~ RIVER, A~ 99~77 [~b~g~ Sheet
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF
ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF
ON-SITE WASTEWATER DISPOSAL SYSTEMS.
2. ALL WORK SHALL BE IN ACCORDANCE WITH THE A'I FACHED SPECIFICATIONS.
5. SCOPE OF WORK: INSTALL NEW SEPTIC TANK AND SOIL ABSORPTION SYSTEM.
4. NO GROUNDWATER WAS OBSERVED AS EVIDENCED BY THE SOIL TEST HOLE. IF AN APPARENT WATER TABLE IS
OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 1 6 FEET BELOW EXISTING GRADE NOTIFY THE ENGINEER
IMMEDIATELY.
TH-1 //--FILTER FABRIC
-0.~ --DR SP/ 4.0 1 ~_~'! '!~':'~!I!:'!i~I:II'I~: ~
GP i~ 0.5
GRAVEL BEDDING
6.0 ~ ~ x--4" ¢ DRAIN PiPE
-10-- I,~4:~*~,¢¢ ~-GRAVEL
6.0
-1. I SECTION
No groundwater
monitored
0 0 ~)-r 0
z<~ Z Z
0-~ -~ -~ ~ 01--
4" Dia Pen'Pipe
o~- ~
u. ,,.~ o o Go o ~< F810 HDPE :~<
/
1000 g SEPTIC --
TANK(P) i
',: : ~ , ' ,
PROFILE DEEP T.ENC. SEE DES,CH
DESIGN PARAMETERS LEGEND
PRIMARY SEPTIC SYSTEM
NO. BEDROOM: 5 (450 gpd) --W-~ WATER LINE/ ABBREVIATIONS
TANK SIZE: 1000g WELL RADIUS CU COPPER
PERC RATE = 1-5 MPI DIP DUCTILE IRON PIPE
SOIL RATING: 1.2 GPD/SF -- SS -- NEW SEPTIC TH TEST HOLE
AREA RQD: 375 SF FC FOUNDATION CLEAN OUT
SYS. ~PE: DEEP TRENCH 6.0' E.D. T¢ TANK CLEAN OUT NO.
MIN LENGTH: 51.3 LF C~ CLEAN OUT NO.
USE: M~ MONITOR TUBE NO.
52 LF X 2.5' WIDE, 6' E.D., R.I. RIGID INSU~TION
10' TD DCO DOUBLE CLEAN OUT
TOTAL AR~: 584 SF DV DIVERTER VALVE
FS FLOW SPLICER
NOTES:
9/28/11
FOR CONSTRUCTION P.O. BOX 100217 ZNCHORAGE, AK 99510 ~..' ~¢~,~,
PHONE (907) 272-8218 FAX (907) 272-8211 ~.' ~'.~m ~- ~
Scale
:..
HIGHLAND HILLS ¢4, BLOCK 2. LOT 23 ~.~¢5~'77z"-~- 050-382-57
¢~ Steven R. Ponno~'~
JAMES ~ NORA LABELLE ~¢~¢-. CE 8149 .-;%~ PERMIT NO.
5427 WILD MOUNTAIN DRIVE *~i~'. "~ 0SPl11261
DETAILS EAGLE RIVER, AK 99577 ~.~; ...... ,N%%'~ Sheet
~ ~0~S9~%~
SOILS LOG - PERCOLATION TEST
TEST HOLE 1
SLOPE ./ .7/ / "~ 5:SITE PLAN
1-- OR ORGANICS :,,,, /!/,,-- /,?/~ ~,~,,
POORLY GRADED
4 -- SP/ SANS & GRAVELS
GP 6"MSA
5 -- OCCASIONAL
DONIKER
~ 1 POORkY GRADED
SP SAND W/FINES ·
12 SOFT EASY
DIGGING
13 --
WAS GROUND WATER SLOPE
14 -- ENCOUNTERED? N
15 -- IF YES, AT WHAT
16 DEPTH? -0-' TH
BOH X
17 -- DEPTH TO WATER AFTER
MONITORING? -DRY-
18 -- DATE: 9/21/11
19 READING DATE CLOCK WATER
' TIME NET TIME LEVEL NET DROP
READING
DATE PERFORMED: 9/14/11 I 9/14/11 12:22 --- : 5.40 ---
2 ! 12:32 10 MIN 11.42 6.02
3 12:32 --- 5.40 --
4 12:42 10 MIN 11.41 6.01
5 12:42 -- 5.40 ---
6 12:52 10 MIN 11.40 6.00
PEROLATION RATE 1.7 (min/inch) PERC HOLE DIAMETER 6 inches
TEST RUN BETWEEN 5 FT AND 6 FT
COMMENTS: Test hole excavated by A+ HOME SERV!CES. Prec hole was presoaked.
Test run £or one hour. Last 3 readings reposed
PERi~ORMED BY: Steven R. Paxmone~ P.E. ! CERT!?Y THAT TH!S TEST WAS PER¥ORMED !N ACCORDANCE
WJ'I'H ALL STATE AND MUN[C!?AL GU!DL!NES !N Elq;'ECT ON THE DATE O1~ TH!S TEST.
NOTES: ggg.
FO~ CON~T~UCTION P.O. BOX 100217 ANCHORAGE, AK 99510 ..
PHONE (907)272-8218 FAX (907)272-8211 ~' ~~*i, Scole
HIGHLAND HILLS ~4, BLOCK 2, LOT 2~ --~~:-:~¢~":'~r, ~n~= ~ o5o-,82-57
dAMES & NORA LABELLE~a'~J' ~'-. CE 8]49 ...~,~ PERMIT NO.
5427 WILD MOUNTAIN DRIVE
SOILS LOG EAGLE RIVER, AK 99577~I ~ oEss~ ~
READING DATE CLOCK WATER
TIME NET TIME LEVEL NET DROP
READING
1 9/14/11 12:22 --- 5.40 ---
2 12:32 10 MIN 11.42 6.02
3 12:32 --- 5.40 --.
4 12:42 10 MIN 11.41 6.01
5 12:42 __ 5.40 ___
s 12:52 10 MIN 11.40 6.00
t MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEAl_TH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~AILINGADDRESS
~EGAL DESCRIPTION
Well ~ ~ Absorption area Dwelling ~ I PERMIT NO,
~ DISTANCE TO: ~- ~'~'~ ~&~ / D~ ~ .--~__ 7~
~ ~ Manufacturer
~ ~ ~_~~ Materia~,~ No. of compartments
~ ~ Liq. capacity in gallons Inside length Width Liquid depth
/~ ~F ROME~DE:
g~ ~ ~ DISTANCE TO: Well Dwelling ~ PERMIT NO.
~--~) ~ ~ Manufacturer Material Liquid capacity in gallons
~ Well ~ Foundat~n~ Near~st lot li~ PER~
~ ~ DISTANCE TO: ~0~,~ ~ ?~ ~ --
u~ ofeachline , Total lengthoflines Trench width Distance between lines
2j~ No. of lines I-ength~z f -*
N' ~ ~ Top of tile to finish grade Material beneath tile
.~. Total effective absorption area
Length Width Depth PERMIT NO.
Type of crib Crib diameter Crib 8epth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO,
~ DISTANCE TO: Building foundation ~ S~wer line Septic tank Absorption area(si
OTHER
~I.~E.~ATER IA LS/- )
//
SOIL TEST RATING
~NSTALLER ~
REMARKS ~
' :,:-//', '. '": ',~,'"' ....
L
APPROVED DATE LEGAL
72-013 (Rev.
PERMIT NO. ':.' 7802;8]: )
WILD
L..EGFIL LOT 2~ B 2 HILFtND HILLS SUB, LOT SIZE
694-2721.2
100188 SQUARE FEET
T'¢PE OF SOIL. RBSORBTION S'¢STEM IS;: TRENCH
MFINIMUft NUMBER OF BEDROOMS
SOIl, RATING (SQ F'T?BR)= 140
THE REQUIRED SIZE OF 'THE SOIL. ABSORPTION SYSTEM IS:
Il.i:. E F" ]f' Ft = 1. ~..E'~ L. EEI'-.! ~,3i 'l" H := _"1:--: 6 mS R Fi %-' E] L. E::. E F' "'F ~-dl ~--.'
THE LENGTH DIMENSION IS THE L. ENC~TH (IN FEEl') OF ]'HE TRENCH OR DRFIINFIELD.
THE DEPTH OF FI TRENCH OR PIT IS THE DIS'rFtNCE BETWEEN THE SURFACE OF THE
GROUND AND I'HE BOTTOM OF THE EXCRVFFI'ION ¢:IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
file GRAVEL DEPTH IS THE MINIFIIJ[,~ DEPTH OF GRFIVEL. BETWIEEN THE OUTFRLL. PIPE:
AND 'THE BOTTOM OF' THE EXCAVATION (IN FEET).
PERMIT RPPLIC:RNT HAS THIS REL~PONSIBILIT'¢ TO INFORM THIS I)EPFtRTMENT DURING THE
INSTfClLLATION INSPECTIONS OF RNM WEL. LS RDJRC. ENT TO 'rN~S PROPERT~r' AND THE
NUHBER OF' RESIDENCES TI-IRT THE WELL WILL SERVE.
BACKFILLIN6 OF' FINY S~":STEM WITHOUT FINAL INSPECTION RND FIPPROVFII-,. B'¢ TFi~S
DEPFIRTMENT WILL BE SUBJECT TO PROSECUTION
MINIMUM DI$1'ANCE BETWEEN R HELL AND ANY ON-SITE SEI48GE DISPOSAl.. S'¢STEM IS;
21.88 FEET FOR R PRIVB'fE WELL~ OR
'150 ]"0 200 FEET FROM R PUBLIC WELl.. DEPENDING UPON THE T'.r'PE OF PLIBL. IC WELL.
HELl.. LOGS ARE: REg!UIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]..~.0 [:,R'¢S
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAW F~PPI..~P, SPECIFICATIONS AND CONSTRUCTION DIAGRRf'IS fiRE
t~VFtILRBI..E ]"0 INSURE PROPER INSTRL[..BTION,
I CERTIFY THAT
:t: I RM FF~MILIFtR NITlt THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS Ft5 SET
FORTtt B'¢ THE HUNICIPi~LITN' OF RNCHORRGE.
2: I NILL INSTRLL THE SN~$TEf'I IN RCCORDRNCE WITH THE CODES,
~: I UND~FRND THF~T THE ON-SITE SEWER -N~TEM MR9 REQLIIRE ENLRR6EMENT IF THE
RESI[)ENCEI2~ REMODELE[) TO INCLUDE MORE ]}FIN ~: BEDROOMS.
~F P~ CAN]"~}4YLL I S .]~NKE
IS'SLIED =.-r------~ .......... z .... ~.--C~ ........ I;,,,'.E ......: ..... r_._L ........ d 'CS. 2
06'E
Russe# Oyster
694 2774
Soils ~ Fouodations
Performed for:
Legal Description:_
D_e~.~.~ f e~(.~.~
0
2
6~
GEO, ECHNICAL ~ DEVELwPMENT CO.
Box 99, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
SOIL LOG
Name:_ / - *Z- / Tel. No.
Ead Ellis
688-2280
Land Development
14.
No Y
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit Drain Field
Comments: ~--~z :,~-- .-~- ~.-~/~ ~,/~..-~ ~,~ ~._
If ,yes, what depth.~
Performed by: ~ (~.~ C~?'~__
Trrtifirb Britting 11[og
by
A. & L DRILLING COMPANY
BOX 97, EAGLE RIVER, ALASKA 99577 e TELEPHONE 694-2588
OWNER OF LAND DEPTH OF WELL
ADDRESS STATIC LEVEL OF WATER FT.
'2 LEGAL DESCRIPTION DRAW DOWN FT.
DATE - Started Ended GALS. PER HR
PERMIT NUMBER 7 KIND OF CASING
KIND OF FORMATION:
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DRILLER'S NAME
PERMIT NO.
DEPARTMENT ' HEFILTH FiND ENVIRONMEN]'RL. ?.OTEC:TION
825 "L" STREET, ANCHORFtGF., BK.
( 7882(68 )
I::tF:'P L I C FII",II"
Id]Cf:IT ! ON
LEI3PIL
PH't'LLIS JRNKE P.O.
WILD MOUNTFIIN DRIVE
L~_. B~ FII.]HL.MND NIIA_=~ SUE:D
oe, r' EFtGLE RIVER 9':;~?'7 ~:,_.4 .<,'i~_
Lcrr '-~ ~'' , ~. ',- ,-~ ' ,
_ :[~E J. OD::L6~ .:~.F....LlflF..E FEE]'
MINIMUM DISTFINCE BETWEEN A WELL AND F~NV ON-SITE SEWFIGE DISPOSlaL SYSTEM
100 FEET FOR FI PRIVF~TE WELL; OR
t50 TO 200 FEET FROM ~] PUBLIC WELl_ DEPENDING UPON TME TYPE OF F'UBLIC WELL.
WELL LOGS ~RE REQUIRED FtND MUST BE RETURNED TO TME DEPflRTMENT WITHIN ~0 DBMS
OF' THE HELL COMPLETION.
OTHER REQUIREMENTS M8¥ FIPPL"F. SPECIFICATIONS FIND CONSTRUC:TION D][£~GRF1MB FIRE
FIVFIILP]BLE TO INSURE PROPER INS]'FtL. LFITION.
I CERTIF'~' THAT
J,.: I FIM FAMILISR HITH THE REQLIIREI'4EF,ITS FOR or,I-SITE .T.,E. WER.:, FINDI.IELL..::,,, "' '"" FIS z,E[" ....
F'OR. TH B"r' 'T'HE MIJWICIF'ALIT¥ OF tJNL. ItE. RFIQE.- '~ ] *
o. .,.UI)E::,,
~.. I WIL~-INSTALL THE SYSTEM IN FJCC:ORDBNCE WITH ]'HE
......... DHTE-~
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: (907)343-7904
On -Site Water & Wastewater Section Fax: (907)343-7997
Parcel ID 050-382-57
Certificate of On -Site Systems Approval
OSC251373
Expiration Date: //S/2_0aC
Legal description HIGHLAND HILLS #4 BLK 2 LT 23
Site address 5427 WILD MOUNTAIN DR
Current property owner(s) LARET THOMAS M I I I
is The On -site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or conditions:
By: Original Certificate Date: 8/27/2025
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage,
Development Service Department (DSD) issues COSAs based upon representations provided by an
independent professional engineer. The Municipality of Anchorage is not responsible for errors or
omissions in the professional engineer's submittal.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 050-382-57
Complete legal description HIGHLAND HILLS #4 BLOCK 2 LOT 23
Location (site address) 5427 WILD MOUNTIAN DRIVE EAGLE RIVER, AK 99577
Current property owner(s) THOMAS LARET
2. ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: FE-1 Private Well serving # 1 dwelling units
El Other Non-public well as regulated by MOA El Water Storage
n Community Well or Public
4. TYPE OF WASTEWATER DISPOSAL: � Private Septic E] Private Septic serving 2 dwelling units
❑ Holding Tank Fj Community Septic or Public Sewer
5. SEPTIC TANK: RN Steel F-1 Plastic R Concrete R Fiberglass
Age 14 _ See advisory if steel or fiberglass older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS 0 Bed X Deep Trench Fj Wide Trench F-1 Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On -site staff
to verify the accuracy of the information provided.
COSA Fee $_ K Waiver Fee $
Date of Payment W114
COSA # 0,S( 2S1 12 3
Date of Payment
Waiver #
COSA Application—Apr2025.doc
COSA Checklist
Legal Description: HIGHLAND HILLS #4 BLOCK 2 LOT 23 Parcel ID: 050-382-57
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 7/8/78 Total depth 79 ft
Cased to UNK ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 18 in.
Date of flow test for COSA 8/14125
Static water level at beginning of test 25 ft.
Comments
B. TANK DATA
Measured operating fluid level in septic tank 48"
Date of pumping 8/21/25
❑ Required maintenance completed, if AWWTS
Comments:
D. DISPOSAL FIELD DATA
Which system tested (date installed)10/5/2011
® ALL standpipes present per record drawing
Total measured depth from grade 10.8 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 2200 gallons 8/13/25 date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Comments/Deficiencies:
COSA Checklist May2025 A=
Well production at time of test 5+ gpm
Water storage tank volume None gallons
Well disinfected for coliform test? ❑ Yes ® Nc
® Coliform bacteria is Negative
Nitrate 3.11 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
Collected bye Date 8/13/25
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 8/14/25
Results f R Pass
Fluid depth prior to test 29 in
Water added 630 gal
New fluid depth 62 in
Elapsed time 1440 min
Final fluid depth 29 in
Absorption rate 450 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 72 in (aeons' ED)
Effective depth used 29 in (Final Fluid Depth)
Effective depth remaining 43 in
E. SEPARATION DISTANCES
From Well on Lot to: (Please enter distances if less than required)
Septic Tank/Lift Station on Lot > 100'
® Yes
if No ft
Neighboring Tank > 100' ® Yes
if No ft
Disposal Field on Lot > 100' ® Yes
if No ft
Neighboring Disposal Fields > 100'
® Yes
if No ft
Sewer Line/Main > 100' ® Yes
if No ft
Sewer Manhole/Cleanout > 100'
® Yes if No ft
Sewer Service/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 Disposal Field(s) on Lot to: (Please enter distances if less than required)
Tank to Foundation > 10' 0 Yes if No ft Surface Water > 100' ® Yes if No ft
Field to Foundation > 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/Service Line > 10' ® Yes if No ft
F. ENGINEER'S COMMENTS
Wells on Adjacent Lots:
Wells > 100' ® Yes if No
Community Wells > 200' ® Yes if No
If tank or field is under driveway comment below
ft
ft
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 08/22/2025
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 & FWCS
COSA Checklist_May2025 .docx
/ Curtis Huffman /
��� �c�'jl • . 08/22 2 5 1.. •v��`',!�
•......
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
~IUsH! i (907,343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. o5o-38a-57
GENERAL INFORMATION
Complete legal description
Expiration Date:
Highland Hills #4, Block 2, Lot 23
Location (site address) 5427 Wild Mountain Drive
CUrrent Property owner(s) James & Nora Labelle
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
5/+27 Wild Mountain Drive
Day phone
Day phone
- es~ ,,,hePwtse-reouested:-COSA.w#l-be.held-hv-D,~r)-fnrntc#~¢r~;
3
NUMBER OF BEDROOMS:
TYPE!OF WATER SUPPLY:
Individual Well
IndiVidual Water Storage
Community Class ~
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Well
[] Individual On-site
[] Individual Holding Tank
[] Community On-site
[] Public Sewer FI
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 sample results. (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 bedroom§ and type of structure indicated herein. I further verify that based on the information
obtained from the ~uniCipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or'wast~vater d sposal system is(are) in compliance with all applicable Mu~nicipaFand State codes,
ordinances, an~i regulations in effect at the time of installation. ' '~ ~ :;i~i~i.~
Name of Firm Pannone Engineering Services, LLC Phone 272-82~.8
Address P.O. Box ~oo2z7, Anchorage, AK 995zo
Engineer's Printed Name Steven R. Pannone, P.E. Date /~/'t/'//t'/
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guideliaes & Regulations. The reported results describe 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 soil condition, ground water
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 this system. All systems eventually fail and
satisfactory test results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. PES can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the 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 SlG~IATURE
~ Approved for ~' bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
; .,.ON-SITE
~ . w~t~RAND
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
D. ~ATiON
,:, ~ on ,le~,at in.
~m
SizeJn ga~. ens
"PUmpofr level at
~-.t~s~ted,
in.
Meetsalarm & ~ir~uit requ~ ir~s?.
'SEL~ARA'~ION-~'. -~ ~~LL.ON LOTTO:
~P'ARATIOI~~'~~TtCI~LDING TANK ON LOTTO:
On.. adjace~ lots.,
On-adjacent'lots
Public sewer m~t'
Holding tard~
Mam~e/a~imal:ex~-
Wef/S~onadjacent lots ~oo+
:Water rna~ a.eo+,
Driveway,. parAiag/~i~ .~e ~l~."
and
this' date:.
(Rev.'
Waiver,FeeS
Date ofpayment
ReceiPt Number
No. CE 8149
ASBUILT
-I HEREBY CERTIFY THAT I HAVE' sURvEY-ED THE
FOLLOWING DESCRIBED PROPERTY:
AND THAT NO ENCROACHMENTS EXIST
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNE~ TO DETERkflNE THE ~¢iSTENCE OF ANY
EASEMENTS, COVENANTS~, OR RESTRICTIONS
WHICH DO NOT WEAR oN THE RECORDED .SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOE CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
DATE.
GRID~
FB~
, ~-~",~,~,~ .~,
SEWARD & ASSOCIATES LAND SURVEYING 694-082~
~ ' MUN C PAL TY 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
1. GENERAL INFORMATION
Complete lega description
NHN Wild Mountain Drive
Eagle River, AK ;,;
Day phone 696-6859
Eagle ~iv6r, AK 99577
LocatiDr), (,§ire address or. directions)
.~, {(~ ,,, .. Ar, . -.., -:..,~;, .
::~ &,,ProPect~. owner.. .. ,.~ane. Dc.6e
M~il~nr~ address-,':- 9365 H~nd
;:,' 'Leh"ding agenc~ -'""~?; Day phone.
"%'-':.':~:. ir):.;~_ :.~ . /,?:')
Agent .... '"" ..... . - ·: '....:';. ;~j.'".:},.;,}5~'~};:....':: '~-..
Address" ..... "'"
Day Phone ' .... :' ''': '~'"
'U"Jess otherwi~e'~e~uested, HAA will be held for pickup. '. '~".':"' "~'.:'¢':'?'"!~T. :'-':,";"i!!!:?:.?i:;'.:.i";.i'!'i--'::i',. :'
2. NUMBER'OF BEDROOMS: 5 ~ ? ' ":; '" ';":'"t-"t?"';T;";'"';:;'-:": '"' '~''
3. TYPE OF WATER SUPPLY:
......... "- Individual well
.~..., -:'._ ~ ,,:,~, Community well
.... . ........ ' Public Water
XXX
NOTE: If community well system, provide written confirmation from State ADEC attest-.
ins to the legality and status of system. , ,",.,; .... '~ ]")t, 1 ~, "·
., . .,, · ...... . , -
4. TYPE OF WASTEWATER DISPOSAL: ' ' ' ' ,-,%"
Individual on-site XXX .
· · ~ --, ;,. · ~ -i!., ,.
ng .... ~,. ~ ·' ...-'?~..:;.4....,', ~.~
: Ftoldi ta ~"k'' ;,:-'' ''~'' ' '" .... ' ~ '
' ~~',~,' .... ~ '~1~-...-..,..; _
'; ' community on-site .........
, . ' - Public sewer ... ,,,,,7,¢~,~ · ~,,~\~?:?~;.. ·
, -; ~ \. ':,..
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.. . ·
Sm
STATEMENT OF INSPECTI°N BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 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 ENGINEERING Phone ~t
17034 Eagle kiver i.e~p ~o~ ~i~
Address Eagle River, Alaska 9.95~77 /
Engineer's signature ~Z ~ Date
DHHS SIGNATURE
~ Approved for 3 bedrooms.
Disapproved.
'f-or '" ' ......
Conditional
approval
'q.'~?..
-,
bedrooms, with the following stipulations:
Additiona Comments
Date
..The Mun b pa ty of:A'nchorage. Department of Health and Human Services (DHHS) issues Health Authority
:Approval Certd~cates based only upon the representations given n paragraph 5 above by an independent
p~,oress~na~ e~gmeer reg~stere~ 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 professional engineer's work.
72.025(Rev. 1/91) Back MOA~21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~-c:,¢7.-'"5 ~t~?--- ~creL-,/,.~ Parcel I.D.
A, Well Data
Well type ~¢-~Yr'~.- If A, B, or C, attach ADEC letter. ADEC water system number
Log present(~N) ,.~
Total depth -"] ~' '~'~
Sanitary seal(~kl~ )
Date of test
Static water level
Well flow
Pump level1
Date completed
Cased to ~Lorb Casing height
',/ Wires properly protected (~N)
FROM WELL LOG AT INSPECTION
I%, o g.p.m. ~,b, ~r g.p.m.
Z
SEPARATION DISTANCES FROM WELL TO:
Septic/heldiug tank on lot \ c)~ ¢¢
Absorption field on lot \ o o
/
Public sewer main ~k//~
Sewer service line ~
; On adjacent lots \
; On adjacent lots \
Public sewer manhole/cleanout
Petroleum tank '7~-
WATER SAMPLE RESULTS:
Coliform E) Nitrate
Date of sample: -2-2 7~5'-/ 7-,-,,)o -5'5--
B. SEPTIC/I't~=Bflfl~TANK DATA
Date installed ~' ~ ':' ~ .~ \'~';- '?$ Tank size
Cleanoutb(i~N).
High w~te~, alarm (Y~..
Date ct( pumping
Collected by:
Other bacteria
s & S ENGINEERING
17o~4 Eagle Riwr Leup i[w~
Eagle River, AlasEa 99577
\ ~-%-~ Compartments
Foundation cleanout (Y,~i) ~ Depression (Y~__.~
Alarm tested (Y/N)
~el ~" Pumper '~-~-~- ,
SEPAR,&,TIoN DISTANCES FROM SEPTIC/I. ICLDIN~ TANK TO:
Well(s) on Ioi'. !c~ t-w: ~ .,~ On adjacent lots
To property line \ o ~' Absorption field
Surface water/drainage
Foundation
Water main/service line
72-026 (3/93}° Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION ~ TO:
W~ On adjacent lots
Manufacturer
Manhole/Access (Y/N) ~
,,pump off,, Lev~y. el~t---~-
Cycles~ ~'~'~
Sudace water
D. ABSORPTION FIELD DATA
Date installed ~, ~ \ L~ .-/~
Length '-5~, ~
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) ('(~
Width
L~ ~ ~ ~ Cleanout present
'~ - .?.. '~ .--rd ~"- Results./~:[~il)
System type '-'t-C--e~ r..-G
Total depth ~['
,.~ Depression over field (Y~
('~'~ for ~ Bedrooms
After test 7 *'
~,~,,J~ l~/Jo~,,(,v~ If yes, give date
Soil rating (GPD/FF) / ~t
Gravel thickness ~,,
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots lo ~ Property line ~'z-
To building foundation S--c, ~'F' To existing or abandoned system on lot 'J/~'
On adjacent lots 3 ~ ~ +' Cutbank ~J/~, Water main/service line ) ~ ~
Sudace water [/2 o Driveway, parking/vehicle storage area
Curtain drain ~//A
Well on lot ~ o~ ~
E. ENGINEER'S CERTIFICATION
I ceNfy that I have checked, vedfied, or conformed to all MOA and HAA guidelines in ~this ins~ecEon.
Sign at u re ..... ~:. =?.., .,, ... ~..
Date
H~ Fee $ ~ ' d~ Waiver Fee $
Date of Payme~ ~/- ~ ~ Date of Payme~
Receipt Numar //~-~ ~/?~d?~ Receipt Number
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 DWELL. lNG
1. GENERAL INFORMATION
Complete legal description
Lot 23; Block 2; Highland Hills #4
Location (site add'tess or directions) NHN W/Ed Mou~ain Drive
Property owner
Mailing address
Lending agency
Mailing address.
Agent April
Eileen Rehwald
Day phone
· 3~89 Indian Cove Drive Juneau, Alaska 9980~
Day phone
BUYERS REALTY
Day phone 277-2897
Address 207 East Northern Lights Blvd., Anchorage, Ak
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 "-4
TYPE OF WATER sUppLy:
Individual well XX
Community well
Public water
NOTE:
99503
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
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.
XX
72-025 (Rev. 1/91} Fronl 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 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
Address
Engineer's signature
6. DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
S & S ENGINEERING
17034 Eagle River Loop Road No, ~_0~r
Eagle River, Alaska 99577
Phone
bedrooms1
bedrooms, with the following stipulations:
Additional Comments
Date
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.
72-025 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~-,~-"~ ¢,z'~.¢-'7~ F~RW>,-y&c, ~,~-~ Parcel I.D.
A. WELL DATA
Well type
Log present ~/N)
Total depth
Sanitary seal ((~N) _ ~
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ... "~ - ~-~ ~ Driller
Cased to ~O ~ ~r
Casing height
Wires properly protected ~N)
FROM WELL LOG
Date of test ~ ¢ ~ ¢-i ~
Static water level '~"1 ~
Well flow \"'L.. o
Pump level ~\L
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main ~//~.
Sewer service line
AT INSPEC'I'ION
4,,
g.p.m. /.~.q 4-
~.~
; On adjacent lots _. loC:)
; On adjacent lots \ c~ot 4-
Public sewer manhole/cleanout ~ Ih,-
Petroleum tank '2~J ~¢¢
c_. Z ~
WATER SAMPLE RESULTS:
Coliform
Date of sample: I ~ el ~<j 2_-
Nitrate
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed. ~-I~
Cleanouts ~)'N)
High water alarm (Y~_~
Date of p. umping ~, ¢ ~ o ~o~ 1.-- Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot / ~c:) ~'~ On adjacent lots \ c)c:) ~'~''
To property line \.o .Absorption field.
Surface water/drainage t, C:::'c:~.
Other bacteria /'J o r. LE_
S & S ENGINEERING
17034 Eagle River Loop Road No. ~O,'i
Eagle River, Alaska 99577
Tank size ~'Z.~'o G,,u~cL.- Compartments %
Foundation cleanout (Y/~ ~ Depression (Y/~
Alarm tested (Y/N) /'J/~.
,,./
Foundation LoG ~
--Water main/service line_ ~ ~ 4`
72-026 (Rev. 7191) Fronl
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Manufacturer
"Pump on" level at
Meets MOA electrical codes (Y~-----¢
SEANCE FROM LIFT STATION TO:
VYeql on lot On adjacent lots
Manhole/Access (Y/N)
_ 2'Purffo-off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ~o ~ [ z~ ~-~
Length --z.~ Width
/
Total absorption area
Depression over field (Y/~ /'-J
Soil rating I~o ~/~F--
Gravel thickness L¢,~'
Cleanouts present ~)'N)
Date of adequacy test
If yes, give date
System type
Total depth
Results,~Z:fail) I¢~~'~ for
~.%;roxide treatment (past 12 months)(Y~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ! c~ t"~ On adjacent lots \ oo Property line
To building foundation
On adjacent lots
Surface water \
Curtain drain
bedrooms
E. ENGINEER'S CERTIFICATION
· that I have checked verified, or conformed to all MOA and HAA guidelines in effect~o~,~(l:Le~d~ate of this inspection.
I certlf , ~,,
of.
S&SENGINE~RING ~ . ~ ..
Signature 17034 Eu-ie River Loon ~na~ ~ .~ ~ 49~
~nglneer s Name ' '
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
~ ,M,lub~ t~.113~ C~l'~l'~l(:;l~[~rl-I O R A G E (MOA)
HE~[~~PPROVAL (HAA)
~v'~O~~I~UARY 1984
Legal Description: / ~ 7
RECEi- DZ,
WELL DATA
Well Classification
Well Log Present ~/~1)
//~r- ~ ,./z_ ~C If A, B, C, D.E.C. Approved (Y/N)
/
Depth of Grouting ~:/~/~"~"~'~-' "*
Pump Set At U/, ~.,,, ....
Sanitary Seal on Casing(.~)/N)
Depression Around Wellhead
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
Total Depth -,7 ¢'. ~_ ~ Cased to
Static Water Level ..'~ (¢
Casing Height Above Ground 2- /
Electrical Wiring in Conduit
Separation Distances from Well:
/
To Septic/Holding Tank on Lot /
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot '~/,,/~
; Date / t///¢/,~' '~
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments /~-/{ ~ ~J-
SEPTIC/HOLDING TANK DATA
Date Installed ~//;/,,>¢- _ Size /,2 .F-~-, No. of Compartments ~-
Standpipes ~N). Air-tight Capsc/~F~'N) Foundation Cleanout (Y/.~'
Depression over Tank (Y/~ Date Last Pumped f('*,/¢ ~,~'~>,
Pumping/Maintenance Contract on File (Y/N) ~1.,///,/). ; for /LY~/~/
Holding Tank High-Water Alarm (Y/N) /~..//~¢- Temporary Ftolding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
Te Water-Supply Well ./,~/¢ /
To Property Line ,'-¢ ,Y [
To Water Main/Service Line ¢z--¢ _/ ~
Course /v~,.~ ,~, / ,
/
To Building Foundation
To Disposal Field /~ /'
To Stream, Pond, Lake, or Maior Drainage
:7! ,/
Page 1 of 2
72 026 fRev 8'861 Fronl
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~--- / W --
Width of Field '-,~
Square Feet of Absorption Area
Depression over Field (Y/~r~'
Results of Last Adequacy Test
Type of System Design
Length of Field ~ZT' /
Depth of Field ,/,/
/
Gravel Bed Thickness
Separation Distance from Absorption Field:
To Water-Supply Well f~7z(~ r
To Building Foundation ~
Lot /q///~
To Water Main/Service Line ,~ FZ~ /
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Standpipes Present ct~N)
Date of Last Adequacy Test /z/,,~/,'~- ~.
/
To Property Line ~ ~2
To Existing/or Abandoned System on
; On Adjoining Lots /~,..//-d-,/
To Cutbank (if present)
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Elect rical Codes (y.~..//~'~''-
Comments
Dimensions
Manhole/Access (Y/N) /
"Pump Off" ~
~t (Y/N)
~ Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that~cked, veritie, d, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~-~'~Lr~"~//L-z~ Date /E//~ z7-//¢?
Company /~:yc ~?~c MOA No. ~'~ ~ ~ z~r~
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72 026 IRev 8/86~ Back
REALTY
DEPT. OF HEALTH &
J~/RONMEN'FAL PROTECTION
MAR .P 9 Jg88
P.O. BOX 774627 · EAGLE RIVER, ALASKA 99577" PHONE (907) 694-2388
25 ~arch 1988
~unicipality of Anchorage
Department of Health & Human Services
On-Site Services Dept. (Att: Laura)
P. O. Box J. 966~0
Anchorage, AK 99519
Re: Lot 23 Block 2 Highland Hills
Dear Laura: O~ ~2 ~'7
The enclosed septic pumping receipt is forwarded for your
departmental records.
Request you also file the attached Engineering and Laboratory
reports in referenced property file.
T~nk You,
~yr~a Jo~ston
As'/ociate Broker
~nc~: a/s
MUNICIPALITY OF ANCHORAGE
[)EPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
IDIVISION OF ENVIRONMENTAL HEALTH
CEFFrlFICATE OF INSPECTION FOR HEALTH AUTHORII'Y APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
(: / . ? ,~-"
Application Date ._.~_/~/_:~'__E~_:
G.E t~,tE FIA L INFORMATION
(c)
, k oubd~vls[o s .--r~6z/-/z-¢~-,¢~ . .
t.cgal Description 0ncludelot, bloc ," . n, ecbon, town~mp, range) ~{.~ghland II, lis S/D
location (address or directions) / - ¢¢ ~/.*/o ( c--~ .......
Apphcant ~s (check one): Lending Institution~;Owner/builder~;Buyer~;Other~ (explain); .
(d) Lending Inshtution *~ ? ::~'~' .!~ Telephone
Address
(ei Real Estate Company and Agent
Address
(f)
Telephone
'~¢;~il"[he HAA to tile following address:
TYPE OF RESIDENCE
Single-Famdy J'~ .Multi-Family b-] Other
..~
Nnmber of Bedrooms .....
WATER SUPPLY
Individual Well ~';~.' Community [] Public .17_]
h ote: ,1 ~ommL ~ ty well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE r~IsPOSAL "
Onsite/tl'~J' Public [] Comrnunity E] Fielding 'rank []
Note: If cornmunity well system, must have written confirm, atio, n from the State Department of Envi~ onrnental Conservation
attesting to Ihe legality and status.
Page 1 of 2 /X/i¢,~,'
ENGINEERING FIRM PFIOVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATi(,~N
As certified by my seal affixed hereto and as of tile validation date shown below, I verify that my investigation
Authority Approval shows that the on-site water supply and/or wastewater' disposal system is safe, functioncl a~j
for tile number of bedrooms and type of structure indicated herein. I further verify that based on the informamm
from the Municipality of Anchorage files and from rny investigation and inspection, the on-site wate~ Supply
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations m
the date of this inspection.
Name of Firm
Address
Date
Telephone
[)HEP A r-q'~ R C) VA,L/ //'.
Approved for 7~~ beO~: by ~~_~~
Approved ............ D,sappro~L /~''~:~ ~:~ Cond,t,onal
Terms of Conditional Approval ~
, ~ ,, /?
The Muncipality of Anchorage Department of Heallh and ~nvEpmmen~al
AppFov~l ceFUfica~es based $Ql~ly upon lhe repFesenta~ons gh~en ~n ~a~h 5 above by an ~ndependen~ pFo~ess~onal
engineer reghstered in the State of Alaska. Th~ DHEF does this
institutionsinordertosatisfycerta~nfederalandst~ter~qu~re~ents Employees of DHEP do not conduct msPeCt',ons
analyze data before a certificate is issued. The Munlc~;~al,ly el Anchorage is not responsible for errors or emission,s
professional engmeer's work.
WELL DATA
I~UNICIPALIT¥ OF ANCI-IO~AG:
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) 'w~xuNMENrAL
CH C US -
Highland
*~--"~/~ ~'~" If A, B, C, D.E.C. Approved
Date Completed _ q' ~¢'/~ ~ Yield
~ Depth of Grouting
Pump Set At ~/~
Sanitary Seal on Casing~
Depression Around Wellhead (~
Well Classification
Well Log Present ~/~)
Total Depth '79 1~4'. _ Cased to
Static Water Level . t..7 "~ !
Casing Height Above Ground
Electrical Wiring in Conduit ~)N,?
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
/ 00 l f''' ; On Adjoining Lots /4./~
/gO/'~
; On Adjoining Lots
/4'//¢/'~- To Nearest Public Sewer
,~7~ To Nearest Sewer Service Line on Lot ~" '
/ / .,, ¥- rdt ' -
B. SEPTIC/HOLDING TANK DATA
Date Installed ¢'lq'* 2~ Size /~¢~'"¢ No: of Compartments ,..2
Standpipes ¢~) Air-tight Caps ~ Foundation Cleanout (~0.
Depression over Tank ~[~...,,~ / Date Last Pumped ~/-/''7¢'~'5~
Pumping/Maintenance Contract on File (Y/N) ././_/,A-- ; for
Holding Tank High-Water Alarm (Y/N) .,"~6/./h' _ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well __ /~ O / f'- To Building Foundation _ ~'
To Property Line /.D r ~ To Disposal Field /cc !
To Water Main/Service Line
Course
Comments
{/0
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Width of Field ~ t/
Square Feet of AbsOrption Area
Depression over Field~
,..
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well / 0¢5 ! ~
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
· Length of Field ¢'~
Depth of Field
Gravel Bed Thickness ~
Standpipes Present ~'.N-')
Date of Last Adequacy Test
.~',~'-'"f/~'/.=,,,~ c "t-o,--~ ~ ~---
/
To Property Line c:~,~
To Existing or Abandoned System on
; On Adjoining Lots
~(/O re_ ) To Cutbank (if present)
Comments
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons
Manhole/Access (Y/N)
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
"Pump Off" Level at
4 Vent (Y/N)
,,~// Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request**
I certi~.y&h~tt I¢¢~y.~1 6b~CJlE~,.verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
'S an~ ¥. ...... ,., ~,.~,¢A.~,,.-7~' Date
Compan¢ ~L''~'' MOA No.
Date of Payment LI * D%--~ *~
Amount: $ /~ ~ ~
Page 2 of 2
72-026 (11184)
'il' DA~L'~"ECEIVED
INSPECTION APPOINTMENTS
TIME .- TIME TiME
~NSPECTOR I NSPE I NSPECT~
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPt. OF , ., ~, ,.
DEPARTMENT OF HEALTH & BNVlRONMENTAL PROTECTIO~q~iRONMEN.i/d
825 L Street - Anchorage, Alaska 99~01
ENVIRONMENTAL SANITATION DIVISION [~PR 7 1980
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWN~R-,-~. ~ ~ PHONE
PROPERTY ~E81DENT {1[ different from above) / - ' PHONE
2, BUYER ---. PHON~
MAILING ADDRESS /
3. LENDING INSTITMT ON
4. REAL~OR/AGENT ,~/ [PHONE'
MAILING ADDRESS
STREET LOCATION~./~ ! : ~) . .~ .
6, TYPE OF RESIDENCE
NUMBER OF~BEDROOMS
l~ SINGLE FAMILY [] One I--] Four
[] Two [] Five
[] MULTIPLE FAMILY [~' Three E] Six
7. WATER SUPPLY
[~ INDIVIDUAL* *ATTACH WELL LOG. Awel
Other
log is required for all wells drilled
[] COMMUNITY
[] PUBLIC UTILITY
since June 1975. For wells dril ed prior to that date, give well
depth (attach ~og if available,) ~ ~:~L__~ ~
8, SEWAGE ~IS'POSAL SYSTEM
~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS NSTALLED,
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 {Rev. 6/79) . /~.. ~ ~ oL~o~. ~Q.]~9~.~'
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 ~
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE iNSTALLED
E~] 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 ISewer Line I Nearest Lot Line
WELL TO:
I
I
Absorption Area to nearest Lot Line
5. COMMENTS
J~PPROV ED FOR ---~,~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED ~
DATE BY~.
April 10, 1900
PhyllJ. s L. Jauke
Pos'I: Office i~ox 567
99577
Subject~ !~t 23 Block 2 Hiffhlan~l Hills
Unit
Approval for. your individual sewer and water fa(~ilities
can no'g be granted until the following items have been
completed ~
(1)
The water analysis report be delivered ~o this
office fro!.,~ Chsm i,ab~ 5633 B S%reet.~ for our
(2)
Your i?er;~.~it for %he ins'ga].lation of an on-~s:tte
Ne haw.~ not received thc af~.-builts of the
installation in this office. If anpriva[:e enqJ.,necr
our review and files.
If there are any further questions~ i>].e~ae conkac% this
office at 264~.4720~
Robert c. ?rat't.~ iI.S.
Associate []Nec iali,~'~t
Security National Bank
!:80 R f3'tre('-t 99501.