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HomeMy WebLinkAboutMANN #2 BLK 6 LT 1 MUNICIPALITY OF ANCHORAGE DE ITMENT OF HEALTH AND HUMAN SER\ --'S Environmental Health Division 8,25 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Phone(s) I Permit No No el Bedrooms LEGAL DESCRIPTION Lei Block Subdivision I fownsh~p, Range, Section TANKS [] SEPTIC [] HOLDING ~ce.¢r- [ q 000 MaterlaISC_e(,( ~ TYPE OF SYSTE~ TRENCH ~ BED ~ W. DRAIN ~ OTNER H FT i FT FJ Fl' ~ fi/~3/¢7 Number of hnos Soil rating WELLS PRIVATE [] OTHER (Identifv) ~aa b-~nn iA, B. C} TotaIDate Installed;Depth[~6'[ F'[ Pasod to -7¢ REMARKS: I-~,~- p i~D~.STANCES ~ ABSOtlPTION TANK FIELD WELL . FOUNDATION WELL I0¢~ ,oC"oE~ N,,4. AS-BUILT DIAGRAM (Show Iocabon ol well. septic system, property hnes, ~oundabon, driveway, water boOes, otc.} FT Scale: ll~ ~ ~n[~ C~m C,O, ~(o~¢ ~P/ ~[~r bP(o~ InspectionsPerformedby: z~ec ~(ar,n ~o~ ~, '~oN ez 7~ Oe~ K ~ .~ ~ ~ cerliI9 tha111~ls insp~c%n was ~erlormed according ~o all ~unicipal and State Duidelines in effect on Ihis date: ~/~ /g ~ HealthDepa.meniApprova,: ~// ~~ Date: [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION [] PERCOLATION ',TEST 825 L, Street, Anchorage, Alaska 99501 '264-4720 ' SOILS LOG- PERCOLATION TEST PERFORMEDFOR: D~f"I~/)~ ~:~tf~.~o,~ / t~-~/'l~/~¢ Pr~?~r'H~r DATEPERFORMED: ~ /1~./ 8 7 LEGAL DESCRIPTION: 1 2 SLOPE 9 13.{4. lO 11 12 13- 14- 15 16 17 18 19 20 THEODORE F, MOORE WAS GROUND WATER ~.~ S ENCOUNTERED? ~' L 0 P IF YES, ATWHAT _ :j.~, E DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop P'ERCO LATIO N RATE TEST RUN BETWEEN /~,/o~ ~-~be (minutes/inch) FT AND -- FT CERTIFIED BY: ~~ ~~ 72-008 (6/79) _~ 0° OD'd-. 160.00' MUNICIPALITY OF ANCHORAG~ H~ ~th and Environmental Prot tion Fourth Floor West 825 L Street D~nchorage, Alaska 99501 264-4720 INSPECTION REPORT ON-SITE SEWAOE DISPOSAL SYSTEM MAILING ADDRESS PHONE SEPTIC TANK: DISTANCE FROM W :LL. "1 MANUFACTURER INSIDE WIDTId. 'J~ __ MATERIAL LIQUID DEPTH NUMBER OF COMPARTMENTS. LIQUID CAPACITY ~OOOGALLONS. TILE DRAIN FIELD: TOTAL LENGTH DISTANCE FROM WELL"J~.g__O_~FOUNDATION ~(~ .NEAREST LOT LINE_~'~._~::~___ OF LINE 'X~ ABSORPTION /",REA ~'"'~' SQ. FT. LENGTH OF EACH LINE _O~ X& DEPTtI: TOP OF TILE l'O F:INISt! GRA©E ~_~ DEPT}I OF FILTER __ MATERIAL BENEAT;4 TILEZ__~'~__ IN. ABOVE TILE ¢]'~ IN. SEEPAGE PIT: ]Log Crib Rings BUILDING FOLJNDATION DIAMETER __ OR VVIDTH ___, LENGTH DEPTI4 Crib Size: DIAMETER .... DEPTt4 DISTANCE FROM: WELL 'FOT~L EFFECTIVE NEAREST LOT LINE___ . ABSORPTION AREA (WALL AREA) SQ. FT. Well Class: Depth: Well Distance To: Lot Line Bldg: Sewer Line: Pipe Materials: It of Bedrooms: Installer: ~[ ~ Remarks: I I I il DATE~__g. _ APPROVED I:::' Ii::: I:;?. I"11 T I",10. IZll:::'1:::' L I CI:::tI",FI" I_ O C I:::i T I O I",1 L lie (:il:::ll .... C:iOI...[)Ei",I 'ill, I lii}] [:,R I_:1. E',6; MF~I',II'4 '.ii;IJE: L. OT SI ZE THE REQU I I:;?.EI:) :E; I ZE Ot::' THE ':'-]O I L. FIB'.:5OI:;?.I::~T I O1",1 S"?E;]"I!L:M I S: THE I....Et'.,IG'I"H [:, I MEt'..IS I ON ]: '.:5 THE LEt",IGTH ,:: 11"4 t:::EET :.', O1::: "I"HIE TI:;;:EI',ICH OF;: t}F'.I:::I I NI:::' I IEL. I}. THE DEPTH OF:' FI TRENC. H OR PIT ].':5 THE [:,I:~ii;TFII",IC;IE E:ETI.,.tEEt'.,I THE :~!;UI;;.!t:::I::tCI!i~ O1:;:' ]'HE GI:;;:OI...IND I::IN[:, THE E',O]"'f'OM OF THE EXC:t:::I',,,'F:ITIOI'-,t ,.i I1'.,! FE:IET::,. "f'I."IE]:;;:E IS I",10 SET I.,.II[:,TH I::'O1:;;: TRENCHI'Z:E;, 'I"HIE G.I:~:FIVEI_ I}EI:::'TH IS THE MINtMIJM [:'EI:::'T'H O1:-: GRFIVEL. BE:'I"t4EEI'-,I TI'"IE CIUTF:'FIL.I... I:::'IF'E; F:It",II} THIE E',OT'f'OM O1::: THE IEXCI:::IVI::ITI'OI'.,I ,:: ]:1'.,t FEET). F:I I:::'f::tC.'I.(t:::IGE t:::'1....1::11'.,1'1" l"ll::l"r' E:[:'i; I N:i;TFIL. L,E[:, t:::IT THE I:::'IEI:;;:M I 'TTI!EE '" S OI:>"I"Z CII'-,I E.:;UBJEC"I" "1"O THI:E F'OM_OI.,.I I tqG COI",I[:, I 'T I O1",1'."!!;: ::L. F'.ITHER I:::1 Cl_l:;:l:i:i;:~i; I O1:;?. t Z NSF I:":It:::'PI:~:O',,,'E[:, t::'L.I::II'-,I'I' ['tl:::l"r' [i)E 2. I::1 COI",t'I" I I'.,tl..IOI.J:iii; MI::! I N"I"IENI::Ii'-,ICE RGREEHI.EI'4T I :El I:;?.Ef..:!l.J I I;i:IEI]:,. I F I:::1 MFI i N'T'I:'!i:i'.,II::!i'.,ICE I::IEiF.':EEMEI'.,IT tS I",IOT KEi:::'T CURREI'-,IT "r'OU MFI"? lii~E RIE'(;K.III~:ED '1"O E']",tM::II:;::GIE THE t:::IE~:L";()RPTIOI",I 'Z;"r'ii;TI!EM I::It",I[:',.'"OR "r'OU I'"II::W E¢IE :BUliiCrI:ECT '1"O F'ROSEC:UTIOI'.,I. M ]: t'.,I I MLIM [.':, I 'Z;T'I:::II'.,ICE E:IETI4EEi'.,I t:::t I.qEl.~l_ I:::IND I::li'.,l'.r' Ot'.,I-.S I "I"IE ':2:;E:I.,tF:tGE I} ): .':..i;PCdSl::lL S"r'E;"f'EM I S :I.EIE~ FiE]ET I:::'Oi:;;: I::1 I::'I:;-.'I',,,'I::ITIE NELL OR ;21;iitE~ FEET I::'Oi:;.: FI I:::'UliilIL]:C I.'.IIELI .... (]TH[El:;;: [;?.E]::!U :[ R!EHE:I",IT'::!!; MI:::I"? I:::ll::'l:::'L."r'. 'L::;F'EC I t:::' I CFIT I Ol",l:i'~; I::II'.,IC, CONSTI:;;:LICT I ON [::, I I::lGt:;?.l::tl"1:i!i; I:::II:;i:E: FIVI:::I I M:::IBLE TO t 1",t:SLIFdZ F'ROI::'ER I NSTI::tL.L.F:Ff' 1 O1"4. I CE[R]"IF:"¢ 'THI:rI'f' :1.: I FIH I:::'FIMiL. I I:::II:;.': 14ITH THE I:;..'IEQUIF.':EHENT:'5 FOR OI",I-".:5tTIE :~:;EI.,.IE::R:!i; F:ti",l[::, I.,.IEL. L.L:i; I::1!:.:; SET FOF.".TH E'?'? THE MLIN :[ C t F'FtL. I T'¢ O1:::' I::INCHOI:;i:FIC~E:. 2: I 14 1 M.... t NSTI:::IL.L. T'HE S"r'STIZM I I",t :::::::::::::::::::::::::::::::::::::::: 14 1 TH THE CODE'Z;. ii:: I LINDI~LR:E;TFII",II:)THI:::FF "I"HE ON-SITE: SIE,HE:I::~'. S"r'STEH MF:IV RE:QUIRE ENLI:::IF;'.GEHENT !F' "l"l"'ll!i: I:;?.E:'.-'.';]:[:'E:NCE IS I:;i:EMO[)E:LEI} TO iI",IE:LU[:'E MORE THFIN GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 PERMIT NO SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT 'NSTALLAT,GN LOCAT,ON INSTALLATION OF: SEPTIC TANK ~ SEEPAGE PIT DRAIN FIELD . OTHER TYPE AN':' S,,E OF FAC,L,TY TO EE SERVED FINANCED THROUGH COMPLETION DATE ANTICIPATED TO BE INSTALLED BY NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEEPAGE area SiZE SEPTIC TANK SIZE TYPE /~ MINIMUM DISTANCES, REQUIREMENTS ~ ~/ FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT ., DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL. SEPTIC TANK ., SEEPAGE PIT . TO NEAREST LOT LINE. WELL TO SEPTIC TANK DRAIN FIELD /Of WATER MAIN tO SEPTIC TANK DRAIN FIELD SEPTIC TANK, , SEEPAGE PIT TO RiVE~, LAKE. STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION S FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETEr CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. , DRAIN FIELD SEEPAGE PIT ALSO CONSIDER AREA WELLS. · SEEPAGE Pit . DRAIN FIELD GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS R./F~)ING ~NSTALLATION, OR LICENSED DESIGNER TYPE DIAGRAM OF ~YSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-6S AND THAT THE ABOVE FORM NO, EQ'OI 6 oGRE,.' 'ER ANCHORAGE AREA BOr Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 UGH INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME'"'~'c~'~'/C'/'"'r'"//'~"' ~/f~"/'~-'-'"~'- MAILING ADDRESS .¢J';~'¢~'~ LOCATION/~/--~ ~ ~'- ~'~,~,(-/~-~'-..-~ .--~5.~-. LEGAL DESCRIPTION /~-~5~'--.'~..,.~g"~_~'~ /*'.,.~,~/(.,/'..~ .4~--~._., SEPTIC TANK: DISTANCE ,,~-,/~/~,..~0)~- NUMBER OF FROM WELL /'~ / MANUFACTURER ~-~'~Z~g~ .~/-//~ MATERIAL J'-~-~---/--~ . COMPARTMENTS ~:)/g/~'- INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY//~:~)~) GALLONS. SEEPAGE PIT: NUMBER OF PITS // DIAMETER ~ OR WIDTI-{'~_~, /LENGTH~Z / DEPTH ' CRIB SIZE: DIAMETER ~ DEPTH ~/' /DISTANCE FROM: LINING MAT E RIAL ~/~/~.L ~/~/--~' TOTAL EFFECTIVE BUILDING FOUNDATION ADDITIONAL ABSORPTION NEAREST LOT LINE,/:` ,~.- ABSORPTION AREA (WALL AREA) ~'~'/_2 S(~. FT. WELL: TYPE ,/.'/~/~////~"~'- CONSTRUCTION BUILDING //_ NEAREST NEAREST FOUNDATION /~ LOT LINE /~ ~ SEWER LINE CESSPOOL ~~ OTHER SOURCES D E PT H DISTANCE FROM: SEPTIC -- / SEEPAGE TANK /"~//--~ , SYSTEM /~> ~'- / APPROVED DISAPPROVED REMARKS DISTANCES: INSTALLED BY: PIPE MATERIAL: / LOT SLOPE: R E M A R KS: Form No. EQ.031 DIAGRAM OF SYSTEM GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-456 l SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT PERMIT NO. LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANR ~ SEEPAGE PIT. , DRAIN FIELD ., OTHER THIS PER.IT iS NOT VALID WITHOUT SOIL TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOIl. TEST RESULTS COMPLETION DATE ANTICIPATED , FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION, ,_...% 7~-/"z., SEPTIC TANK SIZE /~QOO TYPE g ¢~;~¢~.,~g.¢ ¢.~../"~r MINIMUM DISTANCES, REQUIREMENTS ~ / FOUNDATION TO SEPTIC TANK <~ ~ FOUNDATION TO SEEPAGE PIT ~ ~/ ~ ~I DRAIN FIELD SEPTIC TANK TO SEEPAGE Pit WALL /k,~ / SEEPAGE AREA SIZE ' ? , ;? DIAGRAM TO NEAREST LOT LrNE. // DRAIN FIELD ALSO CONSIDER AREA WELLS. DRAIN FIELD FIELD SEPTIC TANR, , SEEPAGE PIT TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION S FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO ~:~OROUGH REGULATIONS REGARDING INSTALLATION. I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-OB AND THAT THE ABOVE DATE APPLICANT'S SIGNATURE A~'l' i 1~' ~/~ /~'~ ;~? C/vi/En.q/n~er$ JAMES W. ROON£Y, P. E. L CONSUL1;,:,dNTS 229 EAS lat. AVE. - P.O. BOX 6087 - ANCHORAC ~,LASKA 99503 TEL~:PHONE 907-279-0483 TELEX 090-35419 Goo/o~/sts Land Surveyors MALCOU.~iA. ~ ENZ ES P E L.S. JAMES FI. WE LLMAN, P.E, RALPH R. MIGLIAccIo Englnoerln~ Oeolo~i~L August 27,' 1973 R & M No. 36657 Mr. Jerry Deval Jack White Company 909 Wes~ 9th Avenue Anchorage, AK Re: Test Hole and Soil Log Report for Sanitary System, Lot 1 South Addition No. 2~ Mann Subdivision Dear ~. DevaI: We are submitting herewith the test boring results and our co~ents regarding soil conditions'encountered at the subject site. This investigation was performed in accordance with your request of August 24, 1973, and those procedures outlined in a letter dated September 13, 1971 by Mr. Rolf Strickland of the Greater Anchorage Area Borough Department of Enviroru-.ental Quality. A single test hole was put down within the Lot 1 area for thc purpose of defining general subsurface soil conditions for the proposed sani~- tary system. Excavation was accomplished with a tractor-mounted backhoe and the test hole ~as extended to a total depth of 14 feet ])alow ground surface. The final log prepared for the test hole has' been :h~cluded in Drawing A-01. Ground water was not encountered in the test hole. ~lla appreciate being given this opportunity to be of service to' ~'ou. Should you have any questions with resard to the above, pldase do not hesit.;zte to contact us. Vexy truly yonrs¢ :,:c; CA&]} A:,i C · O H..; (S :' FA U~,[~AN,KS · TH-1 8-24-73 0.0' O RG:~; I C ~[&TERIAL SAND W/SOME GRAVEL, SOME SILT, OCCASIONAL COBBLE (SM-GH) dense to very dense NO WAI'ER TABLE Hole e,'<ca, vdted v.,iLh Lu:.Lcl. lot'-~l:ot!tlLec] backhoe. 3.0! ]4.0' T.D.- MUNICIPALITY OF ANCHORAGE Department of Heallh & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # //~*'~.) -~)~-/ ~---~ NAA ~ ¢~ - ~L~L~ ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) Location (address or directions) (b) Property owner Mailing Address (c) Lending Institution (d) Mailing Address Real Estate Company and Agent Address ;~ d:)O O '~ '~ Telephone Telephone: (home) Business Telephone ~/- eCrm (e) Mail the HAA to the following address: (or check here~, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family C~ Number of bedrooms 3. WATER SUPPLY Individual Well [] 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 [] Public F'l 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, Iverifythatmyinvestigationofthis 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 ~'(~:'f~ '7"'ec~,'~.t' .C~w~,;¢~w Telephone Address /~/'~¢? ~c~, .~'~'..~ ,/~o,",:a~--Z~ /z~/'.c Date et/" //., t¢~$ 6. DHHS APPROVAL Approved for ~' bedrooms by Approved .,~. Disapproved Terms of Conditional Approval Conditional 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 DHHS do not conduct inspections or analyze data before a certificate is issued. Th,e Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) 8ack Page 2 of 2 C, ABSORPTION FIELD DATA P~,/I-, Soils Rating in Absorption Strata Date Installed 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 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 Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test . To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) D. LIFT STATION N, A-. 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 _~ ~' "~'/~'~ Date Company ~'l~f-./~ T~c4 %~.,~.¢ MOA No. Receipt No. c'~ ~O (~ / - (~ O¢2..~ Date of Payment _ Z¢/ ~¢'-~ 7 -~¢" ? Amount: $ .~, ¢ ~ o O Page 2 of 2 72-026 (11/84) Engineer's Seal ~tJNI, CIPALITY OF / PR 2 ? 1987 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: /" ¢* ~ -~/ Well Classification P r [~,',~ fi,z. Well Log Present (Y/N) N Total Depth b'" / Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line If A, B, C, D.E.C. Approved (Y/N) N, A. Date Completed ~ 17'7¥ Yield '~' Depth of Grouting Pump Set At :;~ :3'o ' Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots N,FI. ; On Adjoining Lots .~. (oo ' To Nearest Public Sewer ~ (67~~ Cleanout/Manhole N,/J', To Nearest Sewer Service Line on Lot N, ~. Water Sample Collected by ?(~/~ 1'~c-~/#~¢~f 5~-~,',¢.e/ ; Date 3/f/ ~ 7 Water Sample Test Results S~c~ - ~ ~o(~ ~ o~ ~r~ b~b ao ~r~r B. S~"PTffCYHOLDING TANK DATA Date Installed ~//'8.f /~ 7 Size ~000~'~1 Standpipes (Y/N) 'r' Depression over Tank (Y/N) 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 To Water Main/Service Line Course ~ foo' Air-tight Caps (Y/N) Y No. of Compartments J Foundation Cleanout (Y/N) Date Last Pumped t~.~..~ ;for ::~.r~ ~ Holding Tank Permit (Y/N) To Building Foundation 5"*..¢" To Disposal Field N,/1.. To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11184) 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 SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) 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 gui,~{~ effect on the date of this inspection. Signed ~~ ~ ~ Date ¢¢~ l¢ l¢¢¢ ¢"~.. ................ ~,,.~t Engineer's Seal MOA No. ~ ~O~'~ Receipt No. ~-~ O~.~ ~ ~5 / ~ Receipt No. Date of Payment ./O '-//~ ~ Waiver Fee: $ Amount: $ /~¢. O~ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 A. WELL DATA Well Classification ~ MUNICIPALITY OF ANCHORAGE (MOA) (,~i~_~/ Health Authority Approval (HAA) ~Y,,,~// CHECKLIST- FEBRUARY 1984 bIU~'L-~'~LIT¥ OF ANCHoP, AGE 343-4744 ~NVIk'ONMENrAk ,SkR'¢IC~$ DWISION Legal Description: Well Log Present (Y/N) N Date Completed Total Depth ~' ! ~'~ I)TY Cased to ~¥¢" Depth of Grouting Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Y SEPARATION DISTANCES FROM WELL: To Scpt',c/Holding Tank on Lot I To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ~ ~r-'~,~¢ ~¢t! B. Sf=Eff:tC/HOLDING TANK DATA Date Installed ¥183{~7 Size Standpipes (Y/N) Y Depression over Tank (Y/N) If A, B, C, D.E.C. Approved (Y/N) N¢~, Pump Set At ~ 3/ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots ~ lc/~,' To Nearest Public Sewer Cleanout/Manhole ; Date ¥t90~¢.1 No. of Compartments Air-tight Caps (Y/N) Y Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line Foundation Cleanout (Y/N) Date Last Pumped io/~"/$,¢ ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 GENERAL INFORMATION (a) Application Date. ~/¢f,I ~7., /'¢ ~7 Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~¢,~"f' ~ h/o.~,<~-¢.f R~.r¢// Telephone: Home ~ '8,7¥ - ,5"o"8~ Business Applicant Address ~/o Fon/~..~,~ ?~,'open,A'~.¢, 3C~oo '~"~-/~/ ,4'~c~,or~ ;, /f-/.~ ¢.P~¢~23 (c) Applicant is (check one): Lending Institution []; Owner/builder [~'; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address ~ o ( (e) Real Estate Company and Agent Address ~ O0 Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family [] Multi-Family[] Number of Bedrooms. 3 Other WATER SUPPLY (; ... Individual 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 Depadment of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84} ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA ~A AND INFORMATION 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 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. ~ further verify that based on the information obtained from the Municipality of Anchorage flies 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 lc: (~h/°/~ 7'~cfin}c~( .~e~'u~c~' Telephone Address IY53~ ~c~o ~/, ~ ~cbor~ ~ ~f~ Date y/ 87 {~7 ', THEODORE F v.~. ~. cE - 3009 ....s~o ~gineer,s Seal 6. DHEPAPPROVAL ~ Approved for ~ bedrooms by te Approved /~_ Disapproved Conditional 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. The DHEP 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 72-025 (11/84) , ['?;'<ANCi~'O~AGE;~ ALASKA";99518 ~' '. '" ' . '/mTE COLt. ECTED ' I T[~ COLLECTED I TYPE ~F SYSTEH / HO~TH' '~Y . ~EAg I, -, ~ ~ I ~ PUBLIC ~ [ND[V[OUAL I ~ RESUBHZT SAHPLE ~ - '--'7 -; ~~ ~ Sample rejected ~cause: I Z;D, .o, O'UBUC'SYSTEMS) CTRCLE CLASS [,.;..,' , ,, ,~.I A . c ~~'? · I NAME OF SYSTE~ .. ' TELEPHONE HUHBER-~ ~ I SYST~H AD~RE~$ . r LOC~TZo~ .,=[ S~L~ .~S C0LL~C'rEo ' 'COLLECTED BY:(SIGNATURE) OF SAMPLE CHECK ONLY ONE THIS COLUMN) ~ DRINKING WATER v~CHECK TREATMENT [-')CHLORINATED [-')FILTERED F~IUNTREATED OR OTHER r-) RAW SOURCE WATER [] NEW CONSTRUCTION OR REPAIRS [] OTHER(Specify) IS THIS'SAMPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMING SAMPLE? [] YES' J~"~NO PREVIOUS COLLECTION DATE ANALYSIS REQUESTED (IF OTHER THAN TOTAL COLIFORM) SEND REPORT TO:(PRINT FUEL NAME,ADDRESS AND ZIP CODE NAME ~(~ ~.~ T'~cA ~kcc/ . ~o~ ~ ADDRESS /~'~'~0 ,~-c~¢ ~.. CITY STATE /~¢~ ZIP CHECK ONE OR MORE []]Sample too long in transit. Sample should not be over 30 hours. [] Sample received too late in week [")Not in proper container [] Leaked out [] Insufficient information provided. Please read instructions on form. []Other (Specify) RECEIVED FRO~ X I' /? , ,'{ RECEIVEO RY ,~.~/',,.~.~_ '.. /..' DATE~ ~ ~-'!~'7, TI~E 0,....,~..'" ANALYTICAL METHOD: ~/MEMBRANE FILTER El FERHEIITAT[ON TUBE Date & Time Started .~-~}~, / Date & Time Completed~.~-~r7 ~'6>o~grt-q LABORATORY RESULTS e [] Other Bacteria ~ Test unsuitable because: ~ Confluent Growt~ ~ TNTC SATISFACTORY ~ ~TISFACTORY BACTERIOLOGICAL WATER ANALYSIS RECORD FOR LAB USE ONLY TOTAL COLIFORMS FECAL COLIFORMS OTHER Membrane Filter: Direct Count Verification: LTB Final Membrane Filter Results Reported By READ SAI~LE COLLECTION INSTRUCTIONS ON BACK OF FORM BGB Date Coliform/lOOml Coliform/lOOml Time A.M. P.M. Page No. Pages ISAACS PUMPING SERVICE (Norm Tibbetts, Owner) 6218 Quinhagak Street ANCHORAGE, ALASKA 99507 (907) 563-3300 PHONE JOB NAME JOB LOCATION JOB PIIONE We hereby submit specifications and estimates for: l ~..~~~t~ ~rll~[l~ hereby to furnish material and labor -- complete in accordance with above specifications, for the sum of: O,.._,..-.~p dollars ($ ) . o be made as follows: All material is guaranteed to be as specified. All work to be completed in a worknlanlike manner according to standard practices. Any alteration el deviation from above specifica- tions involving extra costs will be executed only upoll written orders, and will become an extra charge over and above tile estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado arid other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance, Aathorized Sigl Note: This proposal may be withdrawn by us if not accepted days. Arreptaure lroposal-Tha abo eprices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as spec~ifi~P, aT~/,~ will be made as outlined above. Date of Acceptaace: / ~ Signature #1: Time Date Insp DEPARTM MUNICIPALITY OF ANCHORAG= F OF HEALTH AND ENVIRONMEI ,L PROTECTION L Street, Anchora~a. Alaska 99501 264-4720 3:~//p'm' #2: 2-~-'78 Monday Date Received: Time ~Q,', ,~ Date ~,'~c.-~ ~ February 22, 1978 Time Date REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES ].. Lending Institution Request: Mailing Address: Dhone: 2. Property Owner: Dennis/Elda Jones Mailing Address: Star Route A Box 474W 99507 Phone: 344-2944 3. Legal Description: Lot 1 Block 6 Mann Subdivision #2 4: Single Family Residence: ( Multiple Family Residence: Number of Bedrooms: Three Number of Bedrooms: Well System: Permit # Construction Individual well (~ Community/Public System ( ) Depth of Well 62' Well Log on File ( ) C)' ~" Bacterial Analysis 0 ~ ~, Sewage Disposal System: Permit # Septic Tank Size Absorption Area On-site System (x) Installed 1974 Manufacturer Soils Rate Distances: Well to Septic Tank to Sewer Line Nearest Lot line Public Utility ( ) Installer Material to Absorption Area Absorption Area to Nearest Lot Line Page Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Comments: Lot 1 Block 6 Mann Subdivision ~12 'l ~i Affadavit Attached:~ Approved: r~C~ Disapproved Date: Department Worksheet: ~gV~l$Od 11¥~,I 1VI'tOIJ, VNIJ:~INI llOJ ION --(]](]lAOlld ]gVll]AOI) ,~:INI/ttIISNI ON I POi; ..... -- ' ................... A1NO 335S3~J(la¥ 01. ~3A 130 Ol (o~glsod Snld) ~OD--'IIVIAI fl~iJIL~t~,.'} ~JO:l ldl,~iJ3;~ MUNICIPALITY OF ANCHORAGE DEPARTMEN'F OF HEALTH AND ENVIRONMENTAL PROTECTION 2510 East Tudor Road, Anchorage, Alaska 99504 276-2221 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: CMRO VA 2. Property Owner:_ ~ ~J~,',~ ~ L~/¢t'~j .~,-~ ~ Mailing Address: 5' ~/-~ Tr?~,× ~,/7~/~, FHA Day Phone:_ _CONV ~ 3. Name of Buyer: Mailing Address:_ Day Phone: 4. Name of Lending Institution: ~'~-~ Mailing Address: Phone: 5. Name of Realtor or Agent:. ~ ~ I~.~ ~,~., Mailing Address: Phone: 6. Legal Description: /-~ f- ~ ~//,- ~ 1~ .... .~;~1~ ,,~ ~ Location: ~ ~ ~,,, .~,.i~ ~, r~,,~-,-~- ~/~'/,i ~,'P ('~' "" ~, 7. Type of Facility to be Inspected: 8. Water Supply Type of Supply: No. Bdrms. ~7 Public Utility rlndividual '~ If Individual, number of dwellings presently served If Individual, depth of well (~ ,~' ' Sewage Disposal System Type of System: Public Utility If Individual, date of installation ~/? ~? / Individual (on-site) 72-003(3/76) 06-1220(a) R~v. i973 '' ALA DEPARTMENT OF HEALTH AND SOCIAL Si' 'CES DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI.PUBLIC DATE BACTERIOLOGICAL WATER ANALYSIS INDIVIDUAL El BEMI-PUBLIC [] CHLORINE RESIDUAL PPM REPORT RESULTS TO NAME __ ADDRESS · CITY ZIp CODE ADDRESS OF SOURCE Lab No, OFFICE COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED __ TIME COLLECTED Sample CoJJecled From [] Kilchen Tap [] Bathroom Tap [] Other (Li~t) Well -- [] Dug [] Driven [] Drilled SOURCE: [] Spring [] Cistern [] Other____ Dug Well or Cistern ConstrucHon; Walls--[] Wood ~ Concrete [] Melal Top -- [] Woad Concrete [] Metal LOCATION: [] In Basement [] Basement Offset ~]ln Yard [] Other Buffding Sewer DISTANCE TO: or Olher Drainage pjpe__~__Feet, Tile Seepage Cess- Other Possible Sources of Contamlnallon MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile [] PlasH= Joint Malerlal - Type __ GENERAL: Does Waler Become Muddy or Discolored? When? [] Bored [] Tile Brick or [] Open Top [] Concrele [] Under House Septic TanL Feet Feet. Privy ~ Peet. [] Fibre [~] Asbeslos Cement [] Yes [] No Diameter of Well Well Casing Malarial Diameter Lenglb of -- Drop Pipe Offset in PUMP LOCATION: [] In Wen [] Basement On Top [] Of Well [] Olher __ PURPOSE OF EXAMINATION: Illness Suspected? Deplh Feel. [] In Basemenl [] Room [] Yes New Source of Supply? [] Yes READ INSTRUCTIONS [] No Repairs to System? 06-1220 (b) Rev. ]973 Date Received______ Laclose Broth ON 24 ftours 48 Hours Brilliant Green REVERSE SIDE 24 H .... 48 Hours BEFORE COLLECTING SAMPLE Analysls shows lhis Water SAMPLE to be: ~] Satlsfaclory [] Unsal~sfacfory [] Questionable [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate rellable results. Please send new sample. J~ Boltle broken in transit, please send new sample. Laclose Broth, 24 hrs. __ Coliform Density MF Results SANITARIAN'S REMARKS [] No [] Yes [] No Signature___ BACTERIOLOGICAL WATER ANALYSIS RECORD Reported by This analysis Jndicales Coliform Oganisms fo be: Absent (Most probable No. per 100cc)