HomeMy WebLinkAboutWEST ADDITION KNIK HEIGHTS BLK 2 LT 7West Addition
Knik H
ight
lock 2
Lot 7
017-371
-29
Municipality of AnchorageE�' i
Wit" Z4
On -Site Water and Wastewater Program • (907) 343-7904 LI_E:�') -0 Rage�
ON-SITE WASTEWATER INSPECTION REPORT
` OCTD116 209
ermit Number: OSP181130 PID Number: 017-371-29
Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade
Name:
JOHN & TINA DELAPP
ABSORPTION FIELD -EXISTING
❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
13101 ELMORE ROAD, ANCHORAGE, AK
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Fill added above original grade
Ft.
Gravel length
Ft.
WEST ADD. KNIK HEIGHTS 2 7
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
--
Distance between lines
-- Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Fe
--
-- Ft.
Well
100+
--
--
NA
--
TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Anchorage Tank
Capacity
1 1250 Gal.
Surface Water
100'+
--
--
NA
Material
Steel
Number of compartments
2
Lot Line
51+
__
--
NA
NA
Foundation
*$'+
--
--
NA
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
NA
--
NA
NA
Remarks *Tank placed in same location as orig.
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
tank to maintain 5'+ from field....
Pump make and model
Electrical Inspections performed by
PIPE MATERIAL House to tank 3034 drainfield Tank to
Installer A+3034
Drainfield CO/MT 3034
Inspector ARCTERRA
BENCH MARK (Assumed elevation) 100 ft
Inspeection 1516/8/2018 6/20/18
Location and description
2�d
ction
3rd 4`"
Garage Floor
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
En in
�� \
OF AL4 \
III
Conditional Approval: Date
j `S�' `q'S'
1
10, TH
KENNE'T'H M. OF
1 lc;�A' 7116
Approved a axwy Date 1011712181
' pRo,FL� �a� =i
eer's Stam
Inspection Report_9-1-12.doc
AS -BUILT SYSTEM DETAILS/SITE PLAN
WEST ADDN KNIK HGTS SUBD L7 B2
0
A—C=25.4'
B—C=10,1'
A—D=33.4'
B—D=15.8'
PAVED
D/W
2
v�
Permit ❑SP181130
PID# 017-371-29
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1250 -GAL
SEPTIC
'r TANK
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FINAL GRADE
FILTER FABRIC_
EXISTING FIELD
Q AaV
F
4� 1 PREPARED FOR:
Ip
N 1 JOHN & TINA DELAPP
E ®* LITH 13101 ELM❑RE ROAD
E / ANCHORAGE, AK 99516
1 / � KENNETH M. D I FIELD BOOKS COMPUTED:
w/ CE -7116 kIa / BOUNDARY: N A DRAWN: BMW
ASTAKING: N A CHECK—
A# KMD
.�
P ' ASBUILT: SLS DAA' 6 2O
E ftFESSIO�A Aw
DWG. FILE: GRID: 2836
ACAD FILE: FILE JOB No.: 18-161
SCALE, 1' = 30' -
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'y MUNICIPALITY OF ANCHORAGE t,,,
On-Site Water&Wastewater Program
PO Box 196650 4700 Elmore Road _ 1;
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.org/onsite
\�......__._ .� 1) 1 ar!ni til
��'CN OR pVE
On-Site Wastewater Disposal System Permit
Permit Number: OSP181130 Effective Date: 6/7/2018
Work Type: SepticTank Upgrade Expiration Date: 6/7/2019
Tax Code Number: 01737129000
Site Legal Address: WEST ADDITION KNIK HEIGHTS BLK 2 LT 7 G:2836
Site Mailing Address: 13101 ELMORE RD, Anchorage
Owner: DELAPP JOHN R &TINA D Lot Size in Sq Ft: 46137
Design Engineer: ARC TERRA CONSULTING INC Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field El Septic Tank 0 Holding Tank ❑ Privy 0 Private Well 0 Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
/ -7//�
Received By: �. -� Date: t �y
Issued By: i1► / ,Air.L/_ Date: �n /`�
MUNICIPALITY OF ANCHORAGE
Community Development Department \ Phone: 907-343-7904
Development Services Division ��� Fax: 907-343-7997
On-Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 017-371-29
JOHN & TINA DELAPP 907-529-6282
Property owner(s) Day phone
Mailing address
13101 ELMORE ROAD. ANCHORAGE, AK 99516
Site address 13101 ELMORE ROAD, ANCHORAGE, AK 99516
Legal description (Sub'd., Block & Lot) WEST ADD. KNIK HTS. B2, L7
Legal description (Township, Range & Section)
Lot Size 46,137 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑ Initial ❑ Single Family (SF) `L
(w/wo A D U)
Septic Tank Upgrade Duplex (D) ❑
Holding Tank ❑ Renewal n Multiple Dwellings ❑
Privy (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signatui of operty owner or authorized agent)
Permit/Rush Fees: a t--
Waiver Fees:
Date of Payment: (oI"r1I$ Date of Payment:
Receipt Number: Q6 Receipt Number:
Permit No. QSPt '1(3O Waiver No.
Permit App_9-1-12.doc
., pFtCTE/RR, ,
N ARC ERRA
i
CONSULTING, INC
+.4 % ' ,k 212 E. 51st Ave,Anchorage,AK.99503
d Office(907)868-3791, Fax(907)868-3793
* S4.l.rt NG.'•'7
June 6, 2018
Municipality of Anchorage
Development Services Department
On-Site Water& Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: EMERGENCY SEPTIC TANK UPGRADE PERMIT
West Addition Knik Heights Block 2, Lot 7
The owner has requested we proceed forward to obtain a septic permit to
upgrade the failed septic tank. Per contractor, the tank is nonfunctioning, poses
health / safety concerns and has requested an expedited permit.
We propose to decommission the existing 1250-gallon septic tank per code and
install a new 1250-gallon tank in the same location to serve the existing 4-
bedroom house. 77-rt s- Lr 4 mt ,7 du.'hfors.-vG- tea- 41-yk %‘s4y&. gw
The adjacent lots are served by private water. There is no surface water within
100' of the proposed tank. We do not expect there to be any adverse effect on
adjacent lots by the development of this tank. If you have any questions, please
contact me at 868-3791 / FAX 868-3793.
Respectfully submitted,
ArcTerra Consulting, Inc.
, �-`
Kenneth M. Duffus, . .
Attachments: On-Site Sewer Application
20441 PTARMIGAN BLVD • EAGLE RIVER,AK 99577-8736 • PH(907)868-3791 • FAX(907)868-3793
WASTEWATER DISPOSAL SYSTEM DETAILS
WEST ADD, KNIK HTS. B2, L7
!::;!k S0°07 ' - LS ° E /C.fi".00
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(oS�t FRAME Hoop; 0 1,.
13 .. .. ys 0 N FCC' o 'f 1
�i, 1,,,_ 5 5.5 t
Ssmi C4NA \p`• .- • / T- CO
1. DECOMMISSION EXSITNG TANK ° I \ Q/ a
PER CODE & INSTALL NEW °' Sr4rD t}
1250-GAL SEPT❑IC TANK 10'+ I , uP6tdr • piPES o
FROM FOUNDATI❑N, 5'+ FROM EY!ST/�1t�
EXISTING SEPTIC FIELD, & 100'+ w / 41 P St' c alt .!. \ ° COs 01
FROM PRIVATE WELLS. \\' / /'�'$ ' k
INSULATE TANK IF <4' OF COVER. I / ;, ' POST-71p14,&. \. -
ii
e fNEO
2. CONTRACTOR WILL ENSURE I ,/ q'
•
MINIMUM 2% SLOPE INT❑ TANK. ` i ' s stir
3. CONTRACTOR WILL ENSURE ALL 1 /' / ty/Siii* m
SEPARATIONS TO ADJACENT WELLS, / / p/614 'Vs
�
—
SEPTICS, EASMENTS, PROPERTY � /
LINES, ETC.. /
50.• 05' 0o" E 165,00
Scale! 1'= 40' - • ,
•PAGE 1 OF 1 ° o
h
� . �• Az t PREPARED FORI cTER
y ,�v' ' :It-;,..
` JOHN DELAPP ti rg k 0
*r,, 13101 ELMORE RD. o
49T, / * + ANCHORAGE, AK 99516 �I
• �I,�aG/ . . A
0� ...,,;'S . FIELD BOOKS COMPUTED:
E ` CE-'li , ,w'4' / BOUNDARY:N/A DRA%N: BMW i
' �:,/
1 / / , STAaNG N/A CHECKED: KMD �1 ,�i
tr. 44 / 4 / ASBUILT: { DATA 6/6/1$ �' ...�� \' �i
SSI011� / > ��
DWG.AE: GRID: SW2836 !! CO _NG• _41
69
\`�� Rid NSVI.TING • . e�-
D ADHD F.F.FILE Joe"°4' 18-XXX FR AK.99577:. i
GRE,., ER ANCHORAGE AREA BOR._,JGH
',~.~, .... ,, ,.~' Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION
LOCATION
REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE
FROM WE LL/~7 /
INSIDE LENGTH
MAN U FAC T U R E R,~_,,~'~
INSIDE WIDTH
MATERIAL _ _ COMPARTMENTS
LIQUID DEPTH LIQUID CAPACITY ,./~,¢GALLONS.
TILE DRAIN FIELD:
NUMBER OF LINES /___DISTANCE BETWEEN LINES ,/'~/-./~ TRENCH WIDTH,~¢IN. TOTAL EFFECTIVE
ABSORPTION AREA ¢[~'~') SQ. FT. LENGTH OF EACFt LINE
~ DEPTH OF FLUTER
DEPTH; TOP OF TILE TO FINISH GRADE ¢/ MATERIAL BENEATH TILE ~ABOVE TILE .~ IN,
WELL:
BLIILDING
FOUNDATION
CESSPOOL
APPROVED
_CONSTRUCTION
NEAREST
LOr LINE_ __
, OTIIER SOURCES
DISAPPROVED__
NEAREST
SEWER LINE
DEPTH
SEPTIC SEEPAGE
TANK ____. SYSTEM
REMARKS
DISTANCE FROM:
DISTANEES:
SEWER LINE DEPTH:
p i p E M A T E R i A L: ~¢"'"'"L~
LOT SLOPE:
REMAR~<.S:
DIAGRAM OF SYSTEM
Ti'i!:
249 EAST ~515T AVENUE
C,O N S U LT,,hNFI'$, INC.
P.O. BOX 13007 ANCHORAGE, ALASKA 99503 ' TELEPHONE 907-279-O4S3
.ANCHORAGE
FAIIIB,~NKS
JUN E.-%IJ
October 3, 1975
R & M No. 562082
Mir. Joe Dremer
Ocean Technology, Ltd°
2502 West Northern Lights Blvd
Anchorage, Alaska 99503
Test Hole and Soil log report for Sanitary System
Lots 4 & 5, Block 1 and Lots 1, 2, 4 & 7, Block 2
West Addition Knik Heights Subdivision
Dear Mr. Dremer:
We are submitting herewith the boring logs, percolation results and our
comments regarding soil conditions encountered at the subject site. This
investigation was performed in accordance with your request of September
23, 1975, and those procedures outlined in a letter dated July 15, 1975,
by Mr. Rolf Strickland of the Greater Anchorage Area Borough Department of
Environmental Quality.
A total of six test holes were drilled at the locations sh~n on the at-
tached location diagram. Ail test holes were drilled for defining general
subsurface soil conditions and five additional test holes were drilled to
a depth of 12.0 to 18.0 feet for the purpose of running percolation tests.
Excavation was accomplished with an auger type drilling rig. As illustra-
ted by the accompanying logs, the soils encountered indicated a somewhat
erratic subsoil profile.
A water table was not encountered in any of these test holes.
We appreciate being given this opportunity to be of service to you. Should
you have any questions with regard to the above, please do not hesitate to
contact us.
Very truly yours,
James W. Rooney
Vice President
JWR/;~ED / j a
Encl.
Xc: GAAB
2
3
TH-].
4
TH-8
TH-9
I
I
I
Fairmont Road
Leyden Road
Consultants Inc.
ANCHO.A~E FA,.~ANKS ALASKA
JUNEAU
o~rS 8-8-75 Isc~ 1"=200 'l°w" e¥/VNA/~ Ic~ s¥ PJ
N
OCEAN TECHNOLOGY LTD.
LOCATION DIAGRAM
ANCHORAGE, ALASKA
I~'~OO. NO. 562082 IDWO NO. a-01
TH-8
10-1-75 0.0'
ORGANICS
1.0'
SILT TRACE SAND
,2.0'
GRAVELLY SA2~D SOME SILT (SM)
.12.0'
SILT TRACE SAND (ML)
~15.0'
GRAVELLY SA~ND SOME SILT (SM)
NO WATER T~YBLE
~20.0' T.D.
Log represents location
as shown on Diagram A01
Consultants Inc.
ANCHORAO~ FAIRBANKS
ALASKA
JUNEAU
OC~kN TECHlqOLOGY LTD.
Log of Test Hole
Anchorage, Alaska
, 1"=3' ow~ ICH~oaYWED I~'ROO. NO_._.5_6,2082 IOW~ ,NO, A02
10-2-75 ISCALm , _; .... I mYWED , , .
TH-9
10-1-75
ORGANICS
-0.0'
1.0'
SIL~ TRACE SAND TRACE
GRAVEL (~.)
4.5~
SAND, TRACE SILT TRACE
GRAVEL (SP)
8.5T
SILTY SANDS w/TtLiCE GRAVEL
NO WATER TABLE
20.0~ T.D.
Log represents location
as shown on Diagram AO1
Iq Consultonts Inc.
I~.'1. ^NC,O,~G~ ~A,,S~N~ ALASKA
JUNEAU
OCEAN TECHNOLOGY LTD.
Log of Test Hole
Anchorage, Alaska
10-2-75,. lscaLm 1"=3' IOWN eYWED Ic~,o 9¥ [~-ED ..... IP~OO[,NO. ,.~562082 {ow~ ~o. A03
TH-10
10-1-75
0.0'
ORGANICS
0.5'
SILT TRACE SA~ND (~'~)
3.0'
SANDY GRAVEL TRACE SILT (GW)
10.0'
SILTY SANDS TRACE GRAVEL (SM)
13.0'
SILT TRACE SAND (~.~)
NO WATER TABLE
20.0' T.D.
Log represents location
as shown on Diagram A0t
Consultants Inc.
ANCHORAGE FAIRBANKS
ALASKA
JUNEAU
OCEAN TECHNOLOGY LTD.
Log of Test Hole
Anchorage, Alaska
10-2-75 ]SCAL< 1"=3' IDWNmY %TED ]c>,KoB¥ l,~Jp {PF~OO. NO. 562082]DWeNO. A04, ___ . ..
TH-11
10-1-75
~_ ORGANICS
~a.:... GRAVELLY SAND TRACE SILT
SILT TRACE SAND
r~ SILTY. S~DS w/T~CE
'. o" (s~,O
'~..
NO WATER TABLE
0.0~
0.5'
10.0''
18.0' T.D.
Log represents location
as shown on Diagram A01
Consultants Inc.
ANCHORAGE FAIRB~NKG
ALASKA
OCEAN TECHNOLOGY LTD.
Log of Test Hole
Anchorage, AAaska
10-2-75 1"=3' ow~ 9¥ WED CH~<O '~Y WED Pr~o,z NO. 562082 ow~ No. A05
TH-12
.~10-1-7 5
ORGANICS
-0.5'
SILT TP~CE SAND (~fL)
'1.5'
GRAVELLY SAND TRACE SILT (SW)
3,5~
SAND w/TRACE SILT (SP)
NO WATER TABLE
15,0'
Log represents location
as shown on Diagram A01
Consultants Inc.
ALASKA
JUNEAU
OCEAN TECHNOLOGY LTD.
Log of Test Hole
Anchorage, Alaska
Log represents location
as shown on Diagram A01
TH - 13
10-1-75
I~ ORGANICS
~ ORGANIC SILT TRACE SAND
~ SILT TRACE SAND
7,/, .~,
i:.'i ~
~d..':
.... ' SIL~ S~Y
NO WATER TABLE
0.0~
0.5'
3.0~
(~)
10.0'
18.0' T.D.
Consultants Inc.
ANCHORAGE FAIRBANK~
ALASKA
JUNEAU
OCEAN TECHlqOLOGY LTD.
Log of Test Hole
Anchorage, Alaska
CD (iD 0 0 Ltl 0 {J1 0 kO O0 "-,4 0'~ '..n ,.~ ~,1 I'O ~
0
~o
I-4
~,o
Date completed. ...............................................
Depth of ................................................................ · .......
of
Size casing...: ...... :.. ...... ~. .... :.~ ......... · ..........
.... .- ~ . .!'r / r -- -.~ . ~.,{
Distance to water.. '~..~..~.. ' '~'
Dist~ce to ~ater while pmp!ng......c:;:.~/.~. ....................
:,~....,. llqns
Of ..... ,'.'[:::.' .....................
...: .... ga per ur.
.... ~- Formation '~fr6m ~, "to
Driller
DELTA DRILLING. COMPANY
5RA BOX'"39,4 E~ '* ' ;
ANCHORAGE. ALASKA.99507 , . -
. · ~ DATE RECEIVED
· INSPECTION APPOI NTM F_iNTS ~, A/) .~/~._.~A_ ~.;(,~ ~,
TIME - TIME \ ~ "~--'~/
DATE DATE " DATE
MUNICIPALITY OF ANCHORAGE DEPT. OF
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~IRONME;<T,''.L
825 L Street - Anchorage, Alaska 99501
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY~,~OWNE~ ~ ~ PHONE
PROPERTY RESIDENT (If differe,at from above) PHONE
2, BUYER PHONE
MAILING ADDRESS
3, LENDING INSTITUTION ~ PHONE
I
MAILING ADDRESS
4. REALTOR/AGENT I PHONE
I
MAI LING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6, TYPE OF RESIDENCE
NUMBER OF~BEDROOMS
[~"SING LE FAMILY
[] MULTIPLE FAMILY
I~] One [] Four
~ Two [-] Five
[~]'" Three [] Six
Other
7. WATER SUpPlY
[]' INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8, SEWAGE DISPOSAL SYSTEM
[~'"iN D I V I DUAL/ON-SITE**
[] PUBLIC UTILITY
72-010 (Rev. 6/79)
/
ATTACH WELL LOG. A well Icg is required for all wel~drilled
since June 1975. For wells drilled prior to,gat date, ~ll've~wel
depth (attach log if available.) ~ ~ 0 /
/
-~ YEAR ON-SITE SYSTEM WA~ INSTALLED.
/
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSI
G 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 E~ 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
[]PUBL,C UT, L,TY
Connection Verified INSTALLER
[~]Septic Tank or []Holding Tank
Size: Io~-.~~'-O If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
4 DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL TO:
I
Absorption Area to nearest Lot Line
5. COMMENTS
[~ APPROVED FOR. ,'3 BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
ISAACS PUMPING SERVICE:
(Norm Tibbetts, Owner)
6215 Quinhagak Street
ANCHORAGE, A[_^SKA 99507
Phone 344-0].
Time
Date
Insp ~l~_ _
MIJNIClPALll'Y OF Aiqr'~ ' ,',:~
DEPARTME, OF ltEALTH AND ENVIRON PROTECTION
825% L Street, Anchoraae, Alaska 99501
~. ~ ~_~ 264-4720
Time T me
insp Insp
REQUESP FOR APPROVAL OF INDIVIDUAL SEWLR AND WATER FACILITIES
1. Lending Institution Reques-m-
Mailing Address
Phone:
2. Property Owner: Herzog Construction
Mailing Address
Phone: 277-316 6
3. Legal Descr~pt±on: Lot 7 Block 2 Knik Heiqhts Subdivision
4: Single Family Residence: (x)
Multiple Family Residence: ( )
Number of Bedrooms: Fourt
Number of Bedrooms:
Well System:
Permit tl
Construction
Individual weill (x) Conm~unity/Public System ( )
Depth of Well 205' Well Log on File
Bacterial Analys]_s
Sewage Disposal System:
Permit ti
Septic Tank Size
Absorption Area
On-site System (x) Public Utility ( )
Installed 1977 Installer
Manufacturer
Soils Rate Material
7. Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest ]hot line Absorption Area
to Nearest Lot Line
MUNICIPALITY OF ANCHORAGE
Department of Health and Environmental Protection
825 L Street, Anchorage, Alaska 99501
for Approval of Individual Sewer and Water Facilities
Property Owner:
Mailing Address:
Phone:
Name of Buyer:
Mailing Address:
Phone:
Lending Institution:
Mailing Address:
Phone:
o
6 o
Realtor/Agent:
Mailing Address:
Phone:
Legal Description:
Street Location:
Single Family Residence: ~ Number of Bedrooms:
Multiple Family Residence: ( ) Number of Bedrooms:
'7.
Water Supply: *Individual Well ~ Public/Community System ( )
If Individual Well, well depth _~ /
If Community System, name of system
Sewage Disposal System: On-site System
If On-site System, date of installation:
~) Pub]_ic System ( )
*NOTE: A well log is required on ALL wells drilled since 6/75.
3/77
Page Two
Department of Health and Environmental Prohection
Request for Approval of Individual Sewer and Water Faciliaies
Legal Description: Lot 7 Blodk 2 Knik Heights Subdivision
Commen-hs:
Affadavi% Attached: ( .~
Disapproved:
Letter Attached: ( )
Date:
Department Worksheet: