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Home My WebLink AboutWEST ADDITION KNIK HEIGHTS BLK 1 LT 5WEST ADDITION KNIK H GHT5 lock I Lot - 017-035 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT < [~ UPGRADE LEGAL DESCRIPTION LOCATION ~~ NC. OF BEDROOMSxy ~ Manufacturo~N- Mate~ No. of compartments ~ ~ Liq. capacity ~n ~alions Inside length Wi~- - Liquid depth ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O ~ ~ Manufacturer Material Liquid capacity in gallons ~~ ,o. of ,ines / Length of each~oline , To~ length of ~l~ ,Trencll ~O,~ inches Distance between lin~/~ ~ , ~ ~ Top of tile to finish grade I Material beneath tile J ~ ~ Total effective abs~t~z~a ~en~th ~idth De~th ~ P Type of crib Crib diameter Crib depth Total effective absorption area ~u Well Building foundation Nearest lot line ~ D~STANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO, ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER ~ REMARKS APPROVED ~ /~ DATE - ~EG~L i !';',..ri..q I h,!l !i',!1::~!:!,i' '~F' F:d-:'! ~[;i'"!"i"i'::: .i. '-.,i.'i! I ~.'"": .': '('. ............ /',_ . ...-.,1 ..... .~z~.i~' ~':,l i!ii::i] '~::::::"' 'i!" il..[! '.' :::'~ .'Ii 'Z:: .... :::' ........... i :"'..r: "i! "~. !i :.: x' :::: ~::: ~c:.' :..'~ 4.: i: !:~3' !::::' ~1::::' "fi' !i--il: '"'::" ~OPT~o~V 1"7. 5 ~ 8 6.5 'l ~]!:!' 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Ii: i'O i ?.,!:iii;I..!!:;;:!]: PI,;:('!l:'~:i;F: :i: ?q:!~;'i i::'lL.i..i:!l ): SOILS LOG Soil Type Water Level ~ !-0 ~ 12 ~ 14 16 18 2O Total Depth o~Excavation ~ I, %'- ~ Material at Total Depth Groundwat er L~No t Reached Bedrock ~NotReached Depth, if Reached Depth, if Reached C_las silica tion Method ~Visual ( ) Sieve Analysis () Gary F. Player~ Consulting Geologist CONSULTING GEOLOGIST SOILS LOG ~ ~0 ~c~ ~ 12 ~ 14 16 18 20 Soil Type Water Level Remarks %0O (o- Total Depth of Excavation f~ Groundwat er ~Not Reached Depth, if Reached Classification Method ~Visual ( ) Sieve Analysis () Material at Total Depth Bedrock ~ot Reached Depth, if Reached Gary F. Player, Consulting Geologist FOSS DRILLING 13[~6 Ingra Street Anchorage, Alaska 99501 SIZE OF CA~ING~__~DEPTH OF CASED FEET OF DRAWDOWN. FT. REMARKS DATE C OMPLETED_~_.~.~.~./? PUMP TO BE SET AT ~_t O~ ~t O~ ~to~ mt o~ ~tom mt o~ Parcel I.D. # 1. MUNICIPALITY OF ANCHORAGE BEPARTMENT 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 GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address 'Lending agency ~//~- Mailing address /"4 _ Day phone /4'//'~.. Agent /.,¢' /fA: Address /~///~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~_~ Day phone TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 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. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate 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 .~L~SF-,~ ~q~-._~ bg~.~u~-q'~--~, ~vcS, Phone ~7~/7~ Address ~1 ~~~--~' ./~'~- ~¢. ~0~. Engineer's signature ~//~-~/~~ Date ~ ~ ~ DHHS SIGNATURE ~' Approved for ,~"~-('"V-/_ bedrooms. / DisapprOved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ~,o~-¢~ ~)~¢~<_,u,-~u-~JE~ 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. Empiqyees 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~)25 (Rev. 1/91) Back MOA IY21 Municipality of Anchorage Department of Health and Fluman Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Loq- ~-/ CY--.J. ) ~_~W- H-q"~.~ Parcel I.D. A, Well Data / Well type g'f2-1~6-'-PE~ If A, B, or C, attach ADEC letter· ADEC water system number ~/~. Log present (Y/N) '~ F_--..~ Date completed 5-/f~/7~ Driller Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 Cased to % FROM WELL LOG 1 0 0 / Casing height Wires properly protected (Y/N) '~ g.p.m. AT INSPEfTION SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot il6 I Absorption field on lot I 2~f Public sewer main r~ lA Sewer service line ; On adjacent lots ; On adjacent lots ! __Public sewer manhole/cleanout W/,A- __ Petroleum tank /'4/,,6 WATER SAMPLE RESULTS: Coliform Date of sample: ~'~2~/ Nitrate B, SEPTIC/HOLDING TANK DATA Date installed ,..~-/l£-/-/r~ Tank size Cleanouts (Y)N) \IF--.$' Foundation cleanout (Y/N) High water alarm (Y/N) /I//4 Date of pumping ~'/2./~ x.I ~-.S Depression (Y/N) Alarm tested (Y/N) /',//,4 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO' ._,. . , I Well(s) on lot ~ I ~ On adjacent lots ) IO0 F ~ Foundation To propeMy line ~ ~ / ' Absorption field ~0 / Water main/service line Sudace water/drainage 72-026 (3/9~)* Front C. LIFT STATION ~ Date~'~t,~ed Manufacturer Size in gall~ Manhole/Access (Y/N) Vent (Y/N) "level at "~" Level at High water alarm level ~ ~sted Meets MOA electrical codes (Y/N) SEPAR~FT STATION TO: W¢lot On adjacent lots Surface water D, ABSORPTION FIELD DATA Date installed Length ZFOt Width Total absorption area Date of adequacy test ~ Water level in absorption field before test ~__P~eroxide treatment (past 12 months) (Y/N) Soil rating ('~"P[~42) /.2..5'- ~7..~" System type // Gravel thickness ~;~ / Total depth / ~ __Cleanout present (Y/N) ~ ~ ~ Depression over field (Y/N) Results (pass/fail) p/~'=~'~% for Fo~ ~ Co,-fp~.~-'c-6¢y ,0¢,¥ /.u 5,'¢4PAftertest /',///~ If yes, g,ve date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot l'7-(~ On adjacent lots :~'~ lO0 v-,s,z.,¢:~ Properly line To building foundation ~Z / To existing or abandoned system on lot On adjace~ lots ~ I~ / Cutbank Sudace water ~ 0~~ Driveway, parking/vehicle storage area ~ / Cu~ain drain ~0~ ~ p~ O~l E. ENGINEER'S CERTIFICATION / Bedrooms I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature [~_~. '~ Date ~ / I.~ / C~.~ HAA Fee $ ~ bO Date of Payment fL-//½ "-~, '~ Receipt Number (~Z~j ,_~Z_ (~_./.~ Waiver Fee $ Date of Payment Receipt Number Alaska Water 8c Wastewater Services "Preserving the Last Frontier" ,"3eptember 1,~, 1993 Municipality o'P Anchorage~ [)epartmer~t ef Health and Human Divisien of Envicoru'n~ntal 8epvJces On-*S:ite Services Section P.O. Bex 196650 Anche) r'age, Alaska 99B;Lg-,6650 , /9o,} Mu,,!oq].ah[y ol Al'~ohorago I:)epi, I !eaJth & Human Services Ref: He,~alt;h Authority Approval for Lot Knik Heights, Wo.'-~t S/D To whom Lit; may corloer'rl: Comme. nts regarding the subject: HAg are as follows: 1. Well Adequacy: The wes],], was tested for adequacy by pumping 4.29 gpm 'For- a total of 16.5 minutes (708 gallons). The static level in I;he well was 68 feet bf:,low the top of the well casing. The water level at the end of the test was 88 feet k)e],ow the top of the well casing. Consequen/:,].y, there was on].y a dravx~ewn o'[ 20 fest during th8 entire i;est~ Upon completion of LI'~e test, the well recovered cempletely fn 50 minutes. Bas,sd upon this ¢.nfocmation, the uell wa~s deemed adequalte for a 4 bedroom house (600 gpd). 2. Septic System: The sept:lo system was tested by pumping water inte the c],ean,,,out, at tshe beginning of the trench, ab a rate o'f: 4.29 gpm for a tetal ot: 1.65 minutes (708 gallons). Ac:cord:lng to the J. nil:,ial inspection repot-g, dattad 5/15/78,., the hcench is 8 feet deep~ with 8 feet of cover (16 total aleph;h). I measured the sump to be 13.5 feet deep. At t;he beginning of the test the sump had no water in it~ Ab the end of '[she test the sump st:ill had no water ::[ndiesa~ng that the l;r'ench was abeopb~ng ~ater as fast as ~as being J.n~rodue~ed. Based upon this :i, rrl;or, rnat~on, septZc system ~as deemed to be adequate fop a 4 bedroom house (600 gpd). $. Structural Integrity of Septic Tank: The existing septic tank ;is ever 15 years old. It; was not exposed and physically inspeot;ed~ but it is reasonable to assume bi]at; :.it is approachirlg the ei~d of :i.~s useful life. The homeowner' should anticipate re}placing it during lche next 5 years. There was no depressior~ over it: at this lsime. Telephone - Fax 338-3246 · 8471 Brookridge Drive · Anchorage, Alaska 99504 4. Separation Distances ~o Adjacent Wells and Septic Systera.s: Because of [;he la, Pge ].ol; s:i,.xss, ;I] on],y v~ri'fied the separ'at;ion dist;ances to be grea'l;er t;l'q~n ,tOO 'feet. Ail o'f t;he adjacent; loi;s have privat, e Valdez ·Wp~ 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 GENERAL INFORMATION Complete legal description Location (site address or directions) AY-.., Property owner EFI~¢_~ ~ I~,A¢. I k/AL~'"~- Day phone Mailing address :~- ~ '~:~v/.. Z~I Lending agency ~//~ Day phone Mailing address Agent ~/~" Day phone'5 Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 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. 72-025(Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and typeofstructureindicated herein. I furtherverifythatbased 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 ,4~-£/44 ~A-7",5~ ~ ~,'~"F--~A-7-,5..~ ~'t/d~;, Phone Address ~4-7l ~.oo ' /~-- D~_,~-IVE),z~-J-¢ · /:~-A:, Engineer's signature ~ ~- ~/r~'--'~ -~ ] Date DHHS SIGNATURE ~ Approved for 4 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By; __~ Ot,--~ (--{_ 5~. ,I'~¢- 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. 72A325 (Rev. 1191) Back MOA #21 Municipality of Anchorage ~. Department of Health & Human Services ~:N *4;.L.,:. ..... ~,~,.~ HEALTH AUTHORITY APPROVAL CHECKLIS'r Legal Description: L~OT' [~.~) ~LOC. yL I Parcel I.D. !~,..I !~.. [-.I ¢~lfo~rT~, ) 'Wk=,Br- A. WELL DATA Well type {>~_\x[Aq '-J:~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) \~ ~':':~ ~-) Date completed ~'//~/~? ~ Driller Total depth [ OEP / Cased to. IL'~)¢ ? / Casing height I -- I \ Sanitary seal (Y/N) '~ ['~ ~* Wires properly protected (Y/N) FROM WELL LOG Date of test ~/12'_/'7 r~ Static water level (o~j / Well flow -~ g.p.m. Pump level c~ (.~" SEPARATION DISTANCES FROM WELL TO: / Septic/holding tank on lot I[0. / Absorption field on lot 1'2. O Public sewer main ~/A Public sewer service line I~/A AT INSPECTION MAY 8 ]99t RECEIVED F~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ~0¢~ o6F~d~z~;~fT'p WATER SAMPLE RESULTS: Coliform ~A--T-I~ ICA Date of sample: Nitrate__ /. __ Collected by: Other bacteria ~/q~F/~< f'"'~ ~ 'i 7PF"c/ B. SEPTIC/HOLDING TANK DATA Date installed ,E;//E;/'7 ~'~ Cleanouts (Y/N) _k/p.~: ~ High water alarm (Y/N) Date of pumping Tank size \~_'~O ~r~ t_o~,3% Compartments Foundation cleanout (Y/N) %/~ Depression (Y/N) iq /A Alarm tested (Y/N) Well(s) on lot To property line Surface water/drainage 72-026 (Rev. 3/91) Front MOA 21 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: On adjacent lots ~'' I-7_G- Foundation / Absorption field lC) Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION ~'1//~ Date-installed Size in gallons Vent (Y/N) . "Pfi~mp-on" level at Manhole/Access (Y/N) J ----~;'Pump off" level at High water alarm level ..... - Cycles tested Meets MOA electrical codes (Y/N)~f ~--"-"~ ..... = "'-~--'-~- SEPARATION DIST~.ANC~FROM LIFT STATION TO: D. ABSORPTION FIELD DATA On adjacent lots Surface water .... ,~. ~ ~Jl !;g/rV~ System type Date installed ~/1~'/ -/F~ Soil rating 17/-.~' I:'~ Length A,-'O t %O'/ ~/ - Width '% Gravel thickness Total depth Total absorption area (¢~O Pq- '~- Cleanouts present (Y/N) ~ ~ ~ Depression over field (Y/N) I~ O Date of adequacy test D'/~ ,./¢~ Results (pass/fail) ~ ~ for ~'~ ~ ~% Peroxide treatment (past 12 months) (Y/N) ~ ~ If yes, give date N,/~ bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: / / / Well on lot [7_(72 On adjacent lots,~ I+C:) Property line To building foundation ~:~.R ikt //~ On adjacent lots [~/ Cutbank ~' '-7~~' To existing or abandoned system on lot ~ //~' Water main/serviceline Surface water .... Driveway, parking/vehicle storage area ~ . Curtain drain E. ENGINEER'S CERTIFICATION I oertiP that I have oheoked, verified, or oonfo~ed to ~II MOA ~nd HAA guidelines in effeot~4b~,d~tG of this insp~otion. HAA Fee $ \-~ (Z, Date of Payment Receipt Number Waiver Fee: $ Date of Payment ~'~ C//~,','~ [ Receipt Number ./ Alaska Water 8c Wastewater Services "Preserving the Last Frontier" lq,'4y ('~, ],991 H6~alth Authority Approval (HAA); Knik Heights Subdivls±on, Nest., Lot_~, t31od~ I .. ~ys:~lce)m ].o(so, bec] al; Kni. k Height. s SLlbdJ, vJ. ss'i.()lq ~ Ne~s'i:, Lob ~, .3. I~h(~r',9 i,% ;:~, "c~r'~!d(';" dr'a:i, nag(:~ d:~.l:.ch i,ghi(.;[i r'LIr/s par'alii,(?,], 131'agt"a¼~ ,~}t,. 'lhe '.sepa, r-als,~.or~ dJs?,'i.',an('se b(};LN(s(an 1;he .sopt:::ic Telephone - Fax 358-$246 ® 8471 Brookridge Drive ® Anchorage, Alaska 99504 and MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL F/~(~-~l~'~3c~ OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION IMUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lo{- ~ [~ Ioo~. I., Location (address or directions) (b) Propedy Owner ~ Mailing Address t ~7 ~/ ~raff~., (c) Lending Institution Mailing Address / rd) Real Estate Company and Agent Frr ~n¢ ¢~¢r A'¢ Address Telephone re) Mail the HAA to the followina address: or: Check here ~, if hold for pick up. List contact person and day phone number below. ~e~ t~ Telephone: Home Telephone Business /%4. TYPE OF RESIDENCE Single-Family [] Number of Bedrooms WATER SUPPLY Jndividual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [] 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. 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'SNOI.LO3dSNI 9NIOIAOt:td I/',lal..4 9Nla~I:INION:~ MUNICtP^LII'¥ MUNICIPALITY OF ANCHORAGE (MOA) OF ANCHO~,~LTH AUTHORITY APPROVAL (HAA) DEPT, OF HEALTH & ENVIRONMENTAL PROTE~iON CHECKLIST- FEBRUARY 1984 264-4744 APR g 0 1988 L~g~ Description: RECEIVED WELL DATA ~(~c~ ~ J Well Classification Well Log Present (Y/N) Total Depth I00 ' Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot ~r'l~/c,f'~ If A, B, C, D.E.C. Approved (Y/N) ~' Date Completed .¢'/' I",-/ ?¢ Yield Cased to _IOO '____ Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) (Id" -~_ c.~-,. ; On Adjoining Lots ~ To Nearest Edge of Absorption Field on Lot _~/.30 On Adjoining Lots To Nearest Public Sewer Line /t, ~, ___ To Nearest Public Sewer Cleanout/Manhole R, 4, __ To Nearest Sewer Service Line on Lot Water Sample Collected by _-"FFi'"I / ~='l~f/~¢ '7:~¢A .C~cr ; Date ~/Iz/ Water Sample Test Results Comments (Oo /~,//-, B. SEPTIC/HOLDING TANK DATA Date Installed ~-/fS'l 78 Size / Standpipes (Y/N) Depression over Tank (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 II.¢" v-c,-~m c.~. To Property Line ~. ~o ' To Water Main/Service Line Course ~. ~o' No. of Compartments '~ Air-tight Caps (Y/N) ~' Foundation Cleanout (Y/N) Date Last Pumped '~' [ ~/~ h', 4. ; for N, ~. Temporary Holding Tank Permit (Y/N) R,,¢. _ To Building Foundation I ?' =F~,-,,, c. ~. To Disposal Field I ~ /~¢,"~'-' ¢. o. '~' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72 026 trey R 86/ Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed .5'-/ /o-----------------g~/' Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well f 30 ' To Building Foundation Lot /~,/t. To Water Main/Service Line Type of System Design Length of Field '/'<2 ' Depth of Field ! ~'' Gravel Bed Thickness ~ ' Standpipes Present (Y/N) Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line 3 To Existing or Abandoned System on ; On Adjoining Lots ~ Ye To Cutbank (if present) · A4UN/cIPAL/,. ~NVII¢~ .... ir 01: ~ ~ ,~. "v"~'~4eNTAL $ r~;,':~t'lOl~AeE E,, ~, ~(j~$ DIVISION D. LIFT STATION I\h/Jr, 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) ]988 g£CEIV£D 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 M CA and HAA guidelines in effect on the date of this inspection. Date MOA No. Signed °"~'--~4/-~-¢-/-- Company /~/'cz//~/~ Receipt No..~/ Date of Payment Amount: $ Page 2 of 2 72-026 fRev 8'86t Bac~ Engineer's Seal MUNICIPALITY OF ANCHORAGE ) DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. incomplete requests will not be processed. Please allow ton (10) days for processing. 1. PROPERTY OWNER . ~/~, ' ~"~ PHONE MAILING ADDRESS PROPERTY RESIDENT (if different from above) (J PHONE 2, RUYEFI' PHONE MAI LING ADDR ESS ,/~'~ "'" MAILING ADDRESS 4, REALTOR/AGENT M/~ILING/~DDRESS ~, LEGAL DESCRIPTION STFIEET I. OCATIO~, 6, 'rYPE OF RESIDENCE ¢~Y'-fTf.~'~ ,~ SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS L~ One ~. Four [~ Two ~ Five [] Three ~ Six [] Other 7. WATER SUPPLY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY S. SEWAGE DISPOSAL SYSTEM '"'~-INDIVIDUAL/ON-SITE** BI PUBLIC UTILITY ATTACH WELL LOG. A well log's required for all wells drilled sincgJuQe ~197~5_: For wells drilled prior to that date, give well depth (attach I._og if available,) <::~)¢L~ %~z/~. ~ If individual/on-site, give installation date_.j.~ If system is over two (2) years old an adequacy¢tes~ is required by this Department. NOTE: THE INSPECTIDN FEE MUST ACCOMPANY EACH RI-'QUEST BEFORE PROCESSING CAN BE INITIATED, 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS EZ] SINGLE FAMILY E~ ONE E~ THREE [] FIVE [] OTHER [] MULTIPLE FAMILY E] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL 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 []Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS [] APPROVED FOR BEDROOMS ~ CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION 72-010 (Rev, 3/78)