HomeMy WebLinkAboutKNIK HEIGHTS BLK I LT 13
i~ MUNICIPALITY OF ANCNORAGE
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
WALLING
~EGAL DESCRIPTION --
DISTANCE TO: Well Absorption area Dwelling PERMIT NO.
~ ~ Manufacturer Material No, of compartments
Liq, capacity~n gallons IF HOMEMADE: Inside length Width Liquid depth
Well
Dwelling
(~ ~ DISTANCE TO: PERMIT NO.
.J~
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ Ne~rest]otline , ~ PERMITNO,
'.~ ~ ~ DISTANCE TO: /0 ~ __
--~~ NO. of lines / ~ength o~e?h/line Total length~//of ]ine~ Trench width3~ i,~]es Distance between lin~/~,
~ ~ Top of tile to finish grade Material beneath tile / Total effective absorptiol~ area
Length Width Depth PERMIT NO.
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ ~ Depth Driller Distance to lot ]Me PERMIT NO,
Class
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
SOlk TEST RATING
~EMARKS ~9~1 __~ !
PERMI'T NO.
FIPF'I...ZCFtNT JIJDITH FI. F..iICH 902t GRFINITE PI.FlOE
LOCFITION :SNEI._BI...IF~:NE RORD
LEGlaL. L:OT: i~: BLOCK Z KNIK HTS LOT SZZE
T'T'F:'E OF SOZL RBSORPTION S'.?STEM Z2;: TRENCH
MF~:,.;iIt'IUhl NUMBER OF' BEDROOMS = 3 SOIL RRTZf.,I6 (SQ FT,.'BR)= :tE~7
"FFIE REQUIRED L~IZE OF THE SOIL RBSORPTION '.5'¢STEM
L":,EPFRTMENF L.. HEFILTH FINC, EI',I, IRONMENTFIL. ~..()TECTZON / ~LC,../;./.,,~.~s
',:,",2:~Z '"L.."' 'STF,:EET., RIq}HEF:'R3E. FIK. 9S~501 c:/
2 ~; 4 - 4720
C, ["-,~ ....... :..=...:.7, ]:: 'T" E:"_=, ...... I[=. ~1 .,,..~ EC'_ F~,~'-. F' lEE ~:~:
FEET
THE LENGTH DIMENSION IS THE LENGTH (IIq I--'EET:) OF THE TRENCH OR DRRINFIEL[:,.
THE DEPTH OF FI TRENCH OR PIT I~.::.; TNE [:,ISTFINC:E E:E]"!4EEN THE SIJF..'FRCE OF THE
GROUIqB, FIN[:, THE BOTTOM OF' ]"HE EXE:FI',,,'RTION (IN FEET).
TH[:.:F'..'I!E I:_=; NO SET HI[:,TH F'OR TRENCHES.
THE GRF:I',,,'EL [:,EPTH I2; THE MINIMUM DEF'TH OF GRR',,,'EL. E:ETHEEN THE OLITFF~LL PIF:'E
IRN[:, THE BO'TTOM OF THE EXCFt',?RT]:ON (IN FEET).
FE[.i'II F HFFLI..HI"-,I"f HFI~':'.'; THE RESF'ON":.¥IE:ILIT"r' TO INFORM TI"~I=-, [:'EF'FIRTMEIqT [:,lJR;r.i'.,l(j THE
I N_. ] HI...LI-t I ]. I...IN I NSF'ECT 101',1S OF FflN'¢ .t,.IELLS FIE:,..fFICENT TO TH I :::; F'ROPERT'.r' FINE:, THE;
NIJP'IE',ER OF RE$IB, ENI_-:ES THAT THE HELL 1.4ILL. SEF.:',,,'E.
........... ""Ir' ~.,.!1 ii} ,:". ,=-."-:' ::, Z I["-,~ _-:..,' ..... F' E~" ...... ~-' T]E t-J IP-~ .=,"-- I=~ F-: E I[;~: E ii.:! L! :[ f-,'-~." E:.": ......... IE~', - .............
BFIC:KFILLING OF FIF,I'T' S'¢S'['EM HITHOIJT FINF~L IN.~;F'EC:TION FINE:, HFFF.- ' , -J,PIL,,'" E:'T' TFIIi!:.';
E. EFHF..TME. f~I HILL E:E SIJE:JECT TO F'RLz, EL. U FIUN.
MINIMUi'¢I DISTRNCE BETI-,.IEEN FI I.,.IEI_L RND [aNY ON--SITE SEHRGE DISPOSFIL S"r'STEM IS
::LOO FEET FOR FI F'RI",,'FITE 1.4ELL OR ::t. SC~ TO 200 FEE]' FROh'I R PUBLIC IqELL [:'EF'EI",I[:'II",IG
UF'ON THE T"r'PE OF' F'UBLIC WELL.
MIIqIMUM [:'ISTRNCE FROM FI PRI',,,'RTE HELL TO FI PRIYRTE SEHER [-:[NE I:5 25 FEET FIN[:'
T0 FI C:0MMLINIT'¢ SEWER L. INE :IL=.; 75 FEET.
OTHER RECgJIREMEI",FI'?'; I"lW'r' FfF'PL'¢. :.=.;PECIFICFI"rIONS FIN[:, Ct~dqSTRUCTION DIRGRFd',IS RRE
FI',,,'FIILFIE;I._E TO INSURE F'ROF'ER INSTRI...LFITION.
I CERTIF'T' THRT
t: Z Ri',1 FRi','IIL. IFIR .klZTH THE REC,~UIREMEI".,I]"S FOR ON-SITE '_=,EHER% FINE:.., WELL.':7, FI'E, ::SET
FORTH B'¢ THE MUNICIPRLIT'¢ OF ~RNCHORRGE.
2: I 1.4ILL INSTRLL TFIE S'¢STEM ZN RCC:ORE:..,FINE:E 1.4ITH 'THE
2:: I UN[:,EF..'tSTFtNP.., THFIT THE ON-':~;I~r'E %EI.4ER S"?STEM MR'.? REQIJ.~[;.:E ENL. RF..:GEMENT IF TFIE
RE:F:';IDENCE /IS F.!EMODELEE:, TO INC:L.UC, E MORE THRN Z; BEE:,F.:OOMS.
HF F L. 1L. HN I JIJ.P.. I FF'I fl. R .[
I~;$jLIF--'E:, F~ r .... ~ .... ,z~ ..... [ FTE ............. ',,,',::1..
CONSTF,JCTION
TEST LAB
PERFORMED FOR,
LEGAL DESCRIPTION:
THIS FORM REPORTS:
JUDY RICH
Lot 13 Block
Y'~ Visual Soils Examination
180L W. 48TH AVE. STE. 'C'
ANCHORAGE, ALASKA 99503
248.-13;53
DATE PERFORMED:
Subdivision KNIK HEIGHTS
O Percolotio~ 'rest
9/27/80
DEPTH SOl L
FEET DESCRIPTION NOTES
6" TOPSOIL
_ BRN, SI w/ ORGANICS
2'
- 4' BRN./GRAY SI/CL
SA-GRV 85 sq ft/BR
GW
8' w/ boulders & cobbles
(0_~ SA-CRV to SA
GP-SP 150 sq ft/B
BOTTOM OF HOLE
WAS GROUND WATER ENCOUNTERED YES
IF YES, WHAT DEPTH 14'
LEGEND
® -- Perc zone
®S - Sample taken
· -- Frozen zone
~- Water table
36.56-
GENERAL SITE SLOPE
RFADING DATE GROSS TIME NET TIME DEPTH 'to H20 NET DRAINAGE
PERCOLATION RATE:
PROPOSED INSTALLATION:
COM MI"NTS:
DRAINAGE REQUIREMENTS: See Above
O SEEPAGE PIT ~3 DRAIN FIELD 0 OTHER
TEST- PERFORMED BY:
LS
DATA CERTIFIED BY: Kinney R. Baxter, P.E,
DATE: 9/29/80
~,/~lirlill]l~%,~ ~ DEPARTMENTOF ENVIRONMENTAL QUALITY
b///u, IIII II1! ~,"A%\ 3330 "c" STREET ANCHORAGE ALASKA 99503
SEWAGE DISPOSAL SYSTEM --- APPLICATION AND PERMIT
NA~: OF APPLICANT ~ , :I r ~1 ~ MAIIMNG ADDRESS PHONE
7 ,
INSTALLATION LOCATION '/~//
l~gaL DESCRiPTiON L /7 C Y? ,
INSTALLATION OF: SEPTIC TANK SEEPAGE PIT ~ DRAIN FIELD . OTHER
TYPE AND SIZE OF FACILITY 'ro BE SERVED ~ /)~
~INANCED THROUGH ] ~ TO Be INSTALLED
FINAL INSPECTION: ~4 HOUR NOTICE REQUIRED. B~CKFILLING OF ~NY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE ~UBJECT TO PROSECUTION.
MINIMUM DISTANCES, RE:QUIREMI-'NT$
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIt
SEPTIC TANK TO SEEPAGE PIT WALL
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK ~'/'-~ DRAIN FIELD
DRAIN FIELD
/,9~
, DRAIN FIELD
ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
BEPT,C TANK. /' d :' '. SEEPAGE p,T£O C
TO RIVER. LAKE, STREAM.
SEEPAGE PIT
. D.A,N F,ELO/O¢¢
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION ~ FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit
FITTED WITH AIRTIGHT REMOVABLE CAPS.
4" >
(/// ,/x'?
:w -
LICENSED DESIGNER
GREATER AI~CtlOk/\(;I: Al<LA I;ORt)UG,,
J)epartllletlt of El/vi ronltlen[a] Qua]i L.y
3330 "C" Stre[![
/Nnchorage, A1 as ka 99503
Dep th
Feet
]3 -
14 -
Was ground water encountered?
If yes, at whaC
Gross Time N(:L Time Depbl t;o Watcr
Percol a~ion ra~e minute,
-Proposed ins~allation: Seepage Pit Drain Field
Depth of Inlet ..................... . DepU1
COMMENTS:
180
L_J
174
A
179 '¢~- 181
¥
186
DeArmoun Road Area t%ference Map-P14
.~.,/,-,SlX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPT~ OF
? !7!i,,'~ ¢ ..',
· :,?, RILLED AT THE RATE OF _ PER FOOT,
-:(>~i~OPERTY OWNER
WELL LOG:
_.%,¢,_?':?-0 ..... 231 G~avel wi%h 15~ o~.ay binder. Several cobbles.
?~:~;~ 2) .... 67' Sandy g~avel and small boulders.
:1.82 feet
'.'" 67---128' Clay with 30% sandy gravel°
-:';~- i28--167' 'Hardpan.
'.'"' 167--180' Sandy grave], sho'~lng 'signs of water. Very weak y-leld.
180--184' Water bearing gra, vel producing 5 GPM ~,rlth a 90 foot head , Very fast recovery,
- Cased to !82.' Pu. mp should be -'installed five feet off bottom;'
-" Cost of well seal 5~sta].led: $20s00
'[-:.COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF
DATE.
THANK YOU VERY MUCH.
BERN[F-c-C~AUS OF RAMPART DRILLING WORKS
SERVICE CHARGEOF INa% PER MO Th
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
~)\(~- ~~lzD NAA #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 13; Block I; K~k Heights Subdivision.
Location (address or directions)
13301 Shelburne Road
(b) Property owner FHLMC # 29-389284-9C
Mailing Address
Telephone: (home)
Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address 3201 C Street Suite /t100
Telephone 563-5500
Jack White Company ATTN: George McCoy
Anchorage, Ak. 99503
(e) Mail the HAA to the following address: (or check here.:l~ if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17-034~_- g !eq~.!¥er
Eagle River, Alaska 9957~
2. TYPE OF RESIDENCE
Single-Family E~X Number of bedrooms ,:~'~
3. WATER SUPPLY
Individual Well B3( Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ~X Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, Iverifythat 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 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
Date
5 & 5 ~NGtNEF-RtNG
~.7(334 E. ac~[e p3ver Loop Road No. 204
F. agle River, Ata~ka 99577
Telephone
6. DHHS APPROVAL
Approved for ,~' __bedrooms by
Approved ;~P(.. _ Disapproved Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval
cerificated 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 DHHSdo 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.
,'~ o~ IR~,, vr~l B~ Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA) ~
Uf¥ OF A~"'~-~I~I~G~th°rity Approval (HAA) T- FEBRUARY 1984
MAY 1 7 1990 Legal Description: ~Z._of I .5 ~z2c.~g'.' '~.~ "i
A, WELL DATA
Well Classification
Well Log Present (Y/N)
RECEIVED
~ Date Completed
If A, B, C, D.E.C. Approved (Y/N) ~
Yield _ ~o. ~ ,~/~
(~-._ ~ -~o)
Total Depth
Static Water Level J ~ ~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) _
'Cased to / ¢ 2_ Depth of Grouting
Pump Set At __
;Z. o Sanitary Seal on Casing (Y/N)
~ [)epression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot / CO
To Nearest Edge of Absorption Field on Lot
Public Sewer Line /V'/~
To
Nearest
To Nearest Sewer Service Line on Lot
; On Adjoining Lots / 00
[ //IL ' ; On Adjoining Lots I Z_ / '
To Nearest Public Sewer Cieanout/Manhole
Water Sample Collected by __~ '¢- ~ ~----~'rJ?A2~cC';~J ;Date
Water Sample Test Results .~ F)_~-~ ,~} (- -~-~ ¢- ~./ -- '~fl ~ ~L<:~/' i /
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed / ~ '~ ~ _Size
Standpipes (Y/N) u~ Air-tight Caps (Y/N) _
Depression over Tank (Y/N) /%/
Pumping/Maintenance Contact on File (Y/N) h,)//~
No, of Compartments [
Foundation Cleanout (Y/N)
Date Last Pumped . '.~--- -:] - ~'0
; for /V/~
Holding Tank High-Water Alarm (Y/N) _
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
/
To Water-Supply Well ( CO
To Property Line
To Water Main/Service Line (~ ~ '
To Stream, Pond, Lake or Major Drainage Course
Comments ...~:~0-/-,'~ /~u/~ C_C-'J ~/
Temporary Holding Tank Permit (Y/N) g/~
To Building Foundation '.% '~'
To Disposal Field
72-026 (Rev 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ./,/')-/"']-(¢~ /
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
'¢/~ ,~ Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
~ '-¢-~.. Statndpipes Present (Y/N)
&.J Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course _
To Driveway, Parking Area, or Vehicle Storage Area
/
To Property Line /~
To Existing or Abandoned System on
; On Adjoining Lots / ~¢ /q/--
To Cutback (if present)
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N) %'%
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eff. c~e~'~o._'~.,~t~.t~ of this
inspection.
Signed
~agle River, Ala~k~ 99
Date - .~ //.9 /~ o /~.~.,~ ............... ~,:,,~
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTFIORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a)
Legal Description (include lot, block, subdivision, section, township, range)
t_ol- 1.5
Location (address or directions)
(b) Applicant Name _Z'4,~r~/,~ ~vA,,.,\~s __ Telephone: Home ~""]'~' ¢O,5~ Business
Applicant Address _ ] -~ ~ I ~t ~/_ I~,_D_~x~.~-
(c) Applicant is (check one): Lendin9 Institution E]; Owner/b~dtde~; Buyer []; Other [] (explain);
(d) Lending Institution _~/~4~ ~/J~¢~/-- ~/¢¢/P~ Telephone
(e) Real Estate Company and Agent __,¢(///'~,~,
Address
,- 7 L/
Telephone
TYPE OF RESIDENCE
Single-Family ~ Multi-Family
[]
Number of Bedrooms ',-~
Other
WATER SUPPLY
Individual Well..t'~ Community [TJ Public
[]
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite'~ Public El Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72 025 (11/8,1)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS/FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of lhe 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 further verify that based on tho 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 ~_'~A/JJZ2~A ~--l'J~ /N~l/d~ Telephone ~ ~ ~- ~ 7LD
Address __. ~O.L~, ~IF~ W~ ..~ ~ EL
Date / /~ ~ __
Engineer's Seal
Approved Disapproved ~' OondJtJonal ~_..~).__ _
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. 'Fhe DPIEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MO~l
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
MUNICIPALITY OF ANCHORAG7
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
1986
Legal Description:
WELL DATA
Well Classification P,~IVAT¢/.c, JN61~. k'--A~'uly_ If A, B, C, D.E.C. Approved (Y/N) /'J/4
Well Log Present (Y/N) __y Date Completed _ 7//75 Yield
Total Depth /~4
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Weal:
Depth of Grouting
Pump Set At I
Sanitary Seal on Casing (Y/N) y
Depression Around Wellhead (Y/N) _
N
To Septic/Holding Tank on Lot I~0 ¢ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot __ //'¢~ ; On Adjoining Lots JZ_. J'
To Nearest Public Sewer Line. /,1~.~1~ /N Aff:'=A To Nearest Public Sewer
Cleanout/Manhole _ ~¢NE I~f A~'A To Nearest Sewer Service Line on Lot
Water Sample Collected by ~ U,~DEA ~A. Cl-~'-A~Pgld ; Date IZ./~,f
Water Sample Test Results
Comments ~E¢~'.~ TNA~4 ~' OF- DEAWDoWN ~. ~
SEPTIC/HOLDING 'rANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Size
Air-tight Caps (Y/N) __
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line _ 7
To Water Main/Service Line
Course A/~o^LE /N A~
Comments
IIoOO ~AL No. of Compartments I
)/ Foundation Cleanout (Y/N) ',¢
Date Last Pumped . I~'~
; for ! ~'~
Temporary Holding Tank Permit (Y/N) 4////
To Building Foundation ~7~
To Disposal Field O
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed IR~ ~)
Width of Field 5;
Square Feet of Absorption Area .~ 7,2_.,
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /IV t
To Building Foundation ~/~
Lot NOXlE
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field ,.R/~
Depth of Field 9'
Gravel Bed Thickness ~';
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
'Tl~ ~,q c d
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
I0'
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~¢f-~'./L,¢l,~,~ ~;~('~t,~--~,~'.,~-~ Date /
Receipt No. ~ ~ ~ i'] I
~ ¢ ~:~8~, %-~- Engineer's Seal
Amount:
$
INSPECTION APPOINTMENTS
IM~ ' TIME TIME
DA'r:: DATE DATE
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION r)EP'[.
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION MAR 1 ! 980
Telephone 264-4720
DIRECTIONS: Complete ali parts on page 1. incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER [ PHONE
MAI LING A'~5~S~ ........... ( / .- ,
PR~PERT~ RESIDENT (If different fro~ above) ~t ' ~ PHONE
.~. BUYER PHONE
MAILING ADDRESS
3'." ~ENDING INSTITUTION ~ PHONE
I
MAILING ADDRESS
4. REALTOR/AGENT PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE ~NC~ /'
~ MULTIPLE FAMILY
NUMBER OF~BEDROOMS
~] One ~] Four EZ] Other
~ ,,-~wo E} Five
E~ Three [] Six
7. WATER SUPPLY ~ INDIVIDUAL~
[] COMMUNITY
[] PUBLIC U'TI LITY
ATTACH WELL LOG. A wel Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.)
8. SEWAGE DISPOSAL SYSTEM
[~ INDIVI DUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
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
[] INDIVl DUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED ~/~ ¢
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or E~ Holding Tank
Size: /~OO If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL ¢,~ ~
4. DISTANCES Septic/Holding Tank Absorption Are4 Sewer Line I Nea~eJt Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
E~APPROVED FOR ~.~ BEDROOMS
[] CONDITIONAL APPROVAL (letter ~ccompany certificate)
~DIsAPPROVED r'h[ / \ / .~'~/