The URL can be used to link to this page

Home My WebLink AboutMOUNTAIN MANOR BLK 1 LT 3 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES TANK FIELD WELL lownsh~p, Range, Section AS-BUILT DIAGRAM tShow Iocahon of well. sep~{c system, proporty hnes, loundabon, TANKS ~ SEPTIC ~ HOLDING Mater,al No. oi Compadments :~ ~[~ TYPE OF SYSTEM /~ ~TRENCH I: BED : W. DRAIN : OTHER Depth to p~pe bottom horn Total depth from original grade ~ Gravel depth beneath p,pe , WELLS ~ OTHER (Identifv} ~~'~ RIVATE REMARKS: ("~. ~ (¢4~' ~,:~ ~ ~l Scale: ~ -~ I ENGINEER'S SEAL I 17~~d ~..I. ~;~A. I ~. m..d. .... ~ this ~ion was. peflorme~cordi~ to all Health Depadment Approval: ate: E:.~:;ff:':~l..Jiiil R ]. Vliii]:~. AK Day I i~ c.)ll(.:~ 694-~979 I::.'a t, c r,? l, I d :: 05()..,..~!:~7 1 ,.-.:::22 I.. o L L (:'.{;j a .I. ',: Sub d i ',: .i, s :J, c,n :: MOUNI'A I I".t MAIxlOR L, ot ~- :3 B ]. oc: I.::: 1 Sect ion;: 6 'l"cm~rtsh :i.p: 141'4 IRange: 1W Lot, ::qi:..~,?,~ 'j:.!:~:i~J87 (sq. ~t. c:,P ac:Pcs) Nax B~-.,dl'ooms:~ This Per'rnJ. t~ 1. 'l"otal Capacity: 4 :~?::i~ ~ J. (L} TANI< ~ M :L r't :J. till.tfli I:.o'1:.~i ]. ~M~.~¥:)'I: ~. c:: tal'll< c;i~:¥)a~c:: i'~..y ~ ]. ~ :~50 ga I lons ~ Each sep'L :i. c tar'il:: ii~..~:;~;, h~?~tVE, ¢~:~'1;.. ].~:2a%'~' ~ compar'tments, j)c~l]'~.h 't..o roi:) o~' ~ej::itJ~c: t6M"Ik(:~) .r: 4,,() i ~.k~l AI..L I::'E~]::~ E]'q(?).[NI:~:E]:~'S A't' IFiCHI}~]} L}ES I GN, I%[) I II:::'Y DHHS t:::'RLI:C)R '1'0 i. ,q{':} i ~ NSI:::'I:~C',T I OIq,, 'IH ]:S I;::'t~:RM].'I l S .[ SSUED I:q]R 'Ft"IIZ EX IS'l' lNG 4 BDRM. ] e~ ~-~ ! 1;[::]IxII::E: (]['41..Y i'4ND E:'.XI::" I RES 1;:~:1/3 1/88,, FHA I ii ami ]. J. ar' w:i. tl"~ 't:.,h~:.,e r'eqLt'.J, I"¢~ir~er"~'l:,~.~.i f'c:)r' c)r'l,,-.s:i, te .?~ewePs !::ty the I',h..tr'l:J.c:ip.~,~].:i. ty c::,f' Ar'lc:l"~or'a~le (I"ICI[.t~ ar'id the ins'La].]. '1:.1"~(.~ sysrt, eci~ :J.l'i acc. cmdance v,~:i, th al.I. MOA codes and r, egula't..:i.c:~ns~, comp J,:J. ance w:i. th tl"le des:J, gn (:::l'.j,{,l~)r':J.a (:]f 'Lhis per'mi't',. adher'~;: to a],l IdC)A al'id State of A],aska r.(,::.)quir'emerrl:,,s for' the !se't., bac:k c:JJ, staFIc::es [ PC:)IYI aF/V e).:J, st:i.l"tg ~,~e:l.],, was't.,ewater' disposal system or pub] :i.c: se)v~er'age sr,~qstem on 't.,his or' any adjac:ent or' near'by lot:: uw]c:l[,:~pstarld 'l'.l"la'L. 'l:,,J"lj.~i p~er'm',i,t :i.s va:Lid for' a ~la).(~,fllu/ll Ul'"~der's'~,ar'td {.hat the c::apac::i, ty cif the total, system ~,s 4, I::~edr'ooms and ~:.?r'~].aP(~4emer'rt,, w:[].], r'equir'e ar'l adc:li'l'..iona:t, pePm:i.C. .......... , ......................................................... DATE ~ ........ . .............. SCALE PERFORMED Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGALDESCRIPT,ON:J-~' E1 /~t~J' /'f~/~J'~)/~--' Township, Range, Section: 4 5 6 7 8 9 10 11 12 13 14 15- 16- 17- 18 19 SLOPE -7 / _ / / / ENCOUNTERED? ,,,~p ~/~-~//~,&/ I F Y ES, AT WH ATDEPTH? ~ OL P E Depth to Water Alter/~, ~ ~ Gross Net Depth to Net Reading Date Time Time Water Drop ! PERCOLATION RATE _ (minutes/inch) PER~ HOLE DIAMETER (.~ PERFORMED BY: --" -"i~ ' ~~ CERTIFY THAT T~S TE~ WAS PERFORMED IN Eagle River, ~asK . ' 72-008 (Rev. 4/851 b) DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started PERMIT NUMBER ~ ~ I)I{PTH OF %kLL , ST.VFI(' LEVEL 01: W& rkR I:[ , .. o,~.' :_ .- I)RA~ DOWN FT. GALS. PER HR ~ Ended KIND OF CASIN(; · ' KIND OF FORMATION: From , From ' , From · Ft. to_ ' ~ Ft. - '~ ,: _ .... Ft. to t Ft. ,r' 'I:;'L" "' ~ '' ~--'~ "~ "~ From .... From .Ft. to From----Ft. to.---- From__Ft. to~ From___Ft. to From__Ft. to From___ Ft. to__ __ From Ft. to From_- Ft. to From Ft. to__-- From__--Ft. to. From-- Ft. to From .___Ft. to__ . From____Ft. to_ _ From_ Ft. to Ft. . Ft. Ft. Ft. Ft. Ft. -- ¸Ft, Ft. Ft. Ft, to .... Ft. Ft, to__Ft. Ft. to_ Ft. From ..... Ft. to ____Ft. From Ft. From ..... I't, to ..... Ft. From .... Ft. to~ Ft. Frmn .... Ft. to ..... Ft. From Ft. to ...... FI. From _~Ft. to~ Ft. From Ft. to-- Ft ~uNICIPAU~ OF ANCHO~GE ~. O~ & Ft. to.~ Ft, ENVIRON~ENZAL PRoTECTiON From Ft. to_ _~Ft. From· Ft. to From~Ft. to~_ Ft. Ft Ft. MISCL. INFORMATION: DRILLER'S NAME -- 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 )HONE MAILING ADDRESS [~NEW [] UPGRADE LEGAL DESCRIPTION -~CATION ...~ T/z L tx, Z//~-z5 ~ DISTANCE TO: capacity in gallons DISTANCE TO: IF HOMEMADE: Inside length ITM Well nufacturer DISTANCE TO: / ~'~,~ ~"2 ! line No. of lines 3 of tile to finish grade~, / Length Width Type of crib diameter foundation Dwelling DISTANCE TO: ;lass DISTANCE TO: lines Material ot I i n"~--'--~ Trench wi d t..~ I' ~0 inchas beneath tile inches Crib depth NO. OF BED.~OMS Building foundation )riller Sewerline No. of compartments Liquid depth PERMIT NO. Liquid capacity in gallons Total effective absorption area PERMIT NO. effective absorption area Nearest lot line )istance to Io~ NO. Septic tank 1 AbsorptiOn ~-rea(s) OTHER )1L TEST RATING /~0 ~¢, F~,/'~''/' INSTALLER REMARKS T?..Jl;~' J ::':~"t':T'" "'"h'~:".l':::""l~'~ 're:; (]~ij:;;?;~;tl..ij,.,t[];, j::~.,J[';~ "-J. ~E ~ 7IT"" :')'"J C [': "," 'I'" :::'l:;q:::' ];:~:; i"40 ':::P .... I.,.I];D'I"i"t --,.w:, I'4L.: ........ t:::~?',![:' '"' "l:::~'"T"f'¢'l'"J OF "f'J"'t~Z t' ;""~'" r i:::l~:::'[:::'i,.,. ;( E:f:d",Ff' ~"d-.. , .'.~. i" .:::~ EF;' I,... :;'F'::~; ] :' ENE:E:5 'T'H~::!T THE; ", .......... ¥ "~ "':i "I:::' i::: hu'¢ c '.¢':5'" ~ '" j,J ;!; ........ F'~' l ~','~ '~ ,. 'r [','l . f" D''c'''''¢::~''''':::' ~:',l:::.fl,.IE::,::.t',i 1:'4 ..4J::.Ls. :! ':'~ i:::l ~'"l ':;:'~:::~t: ~::- ::%- ,:::[,;: ';' f,.i 1::~ ~:' t::,,t 1' f": i'" T, ?l;:' ~:;:t;~;(;:¢,.i 't ::':;' ',lP'h4'f :; ["JI:::i'T' ¢::Jl:::'j'::'~ " ¢"' : 'I ', ~ 'j' ~'. ':: ;'F ¢ ..- f..,~' :, r ,~,.,..,, .,:::,i.,...,-~,, ;~;' "r- ~:::'c'¢:;:,"" ,.. I "..~ "r'!,,. :::' i',lL, l~.,i 1' C: 'i' Pi:::tl ,, r- ~ ; ,:;:; c::;i, i E ";~ i:::',~. ' OEtE Russell Oyster 694-2774 Soils ~' Foundations Performed for.' GEO-"ECHNICAL 8 DEVEI. qPMENT Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 SOIL LOG Legal Description: Z~,z~.-, yS~/~. / ( ~ 0,/~' F~,, /" '" Soil Characterlstic~ CO. Earl Ellis 68~- ~'~0 Land Development Tel. No. ~ ~ - ~"~'/J-~' 3 4 Ground Water Encountered: Yes ~ No .. Proposed [nst, all~tton: Seepage If yes, what depth ~.~._ Drain Field_._____ Comments: Performed by :_ Date: MOON ' DRILLING Sfl 'aOX 668, BOGARD RD. PALMER, ALASKA 99645 TELEPHONE '/45-4071 ~.~lk,, ~' ,$ub,,/)l OC,/V/',A~,4/ 21~/-4./J/~ELL LOG · y/ ~ CABIN CASIN FORMATION CABIN FORMATION FORMATION TRIP Glo FROM D. Adams ~ SUBJECT Inspection Fee Refund DATE On May 2, 1978 Duncan McLeod purchased seven sewer and well permits. When the systems should have been inspected the Municipality was on strike. Lot 7 Block 2 Broadwater Heights # 780249 Lot 3 Block 1 Mountain Manor # 780252 Lot 2 Block 1 Mountain Manor and # 780246 Lot l0 Block 3 Mountain Manor # 780247 were inspected by a private engineer. The fees for the above legal descriptions should be refunded. $120.00 @ $30.00 ea. ke~_lg_B%eek-2-Meu~a+n-Ma~e~---+~q~ed-~y-Mun~e+pa~+~Y N/A Lot 7 Block 3 Timberline - expired ~~ 4 Block 1 Mountain Manor - inspected by Municipality 5 Block 1 Mountain Manor - inspected by Municipality McLeod Construction P.O. Box 795 Eagle River, Ak 99577 Redi~rme 4S 471 Poly Pak 150 sets) 4P471 SIGNED DETACH AND FILE FOR FOLLOW-UP DATE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ~(~l~ - L~"-~ ~. '~q,~P- HAA # - ~ GENERAL INFORMATION Complete legal description Lot 3; Bloc~ I; Mountain Manor subdivision Location (site address or directions) 18512 Stillwater Property owner Mailing address Tab Pollo c~ ~/~/~, C/O Don McKenzie R~l Estate Day phone Attn: Cindy Wilson Lending agency Mailing address_ Eagle River, AK 99577 Day phone Agent Cindy W~son/DON MCKENZIE REAL ESTATE Day phone 694-9035 13135 Old Glenn Hwy. Eagle River, AK 99577 Add ress Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: individual well Community well XXX NOTE: Public water 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 XXX Holding tank Community on-site NOTE: Public sewer 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 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 investi_gation 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. & $ ENGINEERING Name of Firm s~.7034 Ea~jte River Loop Koa~...No:~;/04 Phone ~'~'~' ~'~'~'~ ~ Engineer's signature ~ Date o DHHS SIGNATURE X. AP P roved f ° r /~"'c~/¢'- (~7Z/) bedr°°ms' Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ~,,~ _ ~-~ Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Bsck MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. Well Data Well type Log present (~/N) Total depth Sanitary seal ~)/N) If A, B, or C, attach ADEC letter. ADEC water system number Date of test Static water level Well flow Pump level1 Date corhpleted \ ct ~5 % Driller ~ ~ ~L_\ 'J ~,-~ Cased to "~ ~ '~ Casing height t 7.--~ ~ Wires properly protected ~-~N) ~ FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot \ \"7~~ Absorption field on lot Public sewer main Sewer service line AT INSPECTION g.p.m. ~"- ej:ff:m. ,__, i ~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts J~/N) High water alarm (Y~) Date of pumping Nitrate Collected by: Other bacteria S & $ ENGINEERING Eagle River, Alaska 99577 Tank size ~ 3--~- ~ Compartments Foundation cleanout~.~/N) ,-/. Depression /'~ Alarm tested (Y/N) ,g~.~ ~ c,~'~ Pumper ~"~_~[~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: On adjacent lots Absorption field Well(s) on lot To property line Sudace water/drainage Foundation Water main/service line 72-026 (3/93)' F~on! CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" Le~v. el-at~ High water alarm level Meets MOA electrical codes (Y/N) SEPA~TION TO: Wallin lot On adjacent lots Surface water O. ABSORPTION FIELD DATA Date installed ~/~J ~ - ~/~ ~ Soil rating (GPD/FF) ~- Length ~' ~' Width ~-~,~ ~ Gravelthickness Total abso~tion area ~ ~ O ~o~leanout presen~N) ~ Date of adequacy test ~-~ ~ ~ Result~fail) ~ Water level in absorption field before test Peroxide treatment (past 12 months) (~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ To building foundation On adjacent lots. Surface water Curtain drain ~ %-~.~ ~/~--System type ~{'~ ~ ~' ~ ~ ~ Total depth ~ ~ ~ ~ t Depress~n over field (~ ~ for ~ Bedrooms After test If yes, give date ~ On adjacent lots ~ ~ C~ ~ ¥ Property line To existing or abandoned system on lot Cutbank '~l,~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Date HAAFee$ /'7.~ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number WATER WELL ADVISORY_ HEALTH AUTHORITY APPROVAL NO. · recent Health Authority Approval on-site inspection and ~n~fathe potable water supply.w~l~ on ~ ~ Block / ~ /t~-~ /~'~ Subdivision, nn~ 's productivity be ~.~/& gallons per minute. The minimum well was determined tOired-~y t'his department (AMC 15.55) for prqdu~t~vity requ · a ~(~ bedroom residence is g ~/~ gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of noncritical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. 08/0~/95 15:~1 CT&E ENUIRONMENTAL LAB SERUICES ..... coMMERCIAL TESTING & ENGINEERINGCO' ~ ENVIRONMENTAl- LAEIORATORY $15RvICE~ REPORT of ANALYSIS Chemlab Ref.~t :93.3771-5 Client Sample ID :b3 Bi tTTN. M~4OR Matt ~x : ~A~8 Client N~e :~ & 8 ENGIN~RI~ o~ered By :R. S~R 5633 B STREET ANCHORAGE, AK 99518 TEL: (907) 562-2343 FAX~, (gO7) 561-5301 ~OP~ order : 68934 ,. Report Completed :08/03/93 Collected :07/29/93 @ 14:15 hr~ Received :07/30/93 @ 16:00 hr~ Technical Director:STE_?HE~ ~Z ~E ~ Relea,ed By : ~~ ,. Pro~ect Name : Pro;)ect# : :UA - 8ample Remarks: ROUTINE SAMPLE COLLECTED BY; RAY. QC Allowable Ext. Anal ts ual Units Method Li'mits Date Date Init · Re~Ul Q .............................. ]i]iV--7~ Parameter ............................ . .... ~n u~/uz ~ ~ ................................ 1.01 mg/L EPA 353.2/~uu.u ~ Nitrate-N ,:" ~ = Not,~:Anal~ed * ' See Spectal ~nstructions A~ve ** See~S~ple Re~rks qu~tification Iimit~ U- U~etect~, Re'fred value' is the practica~ , D =$econdary -- ~ _ ...... *avl ~n WEST VIRGIN A, NEW JERSEY, SOUTH OARO~INA 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. # 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Location (site address or directions) Property owner Mailing address Tab Pollock 18512 Stillwater Driv~ Ea~l~. Riv~.~: AK 99577 ~I~J Day phone 694-1577 Ea~l~ River, Alaska 18512 Stillwatcr Driv~ Lending agency Mailing address Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 4 NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: XXX ~ Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: XXX '4 Individual on-site Holding tank Community on-site · Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1191) Front MOA #21 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. $ & S ENGINEERING Name of Firm i7G34 Eagle ~,iver Address Eagle River, Ala?~ Engineer's signature 6. DHHS SIGNATURE Phone Date Approved .for ~'o ~,,,~ ~,'~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~c~ ~-~ ~ \ ~"'~-¢t,.~, ~'-'~p~C-~/'r-~ParceI I.D. ~) ~) A. WELL DATA Well type ~ Log present¢/N) Total depth Cased to ~ ~ Casing heiCht Sanitary seal ~/N) Date of test Static water level Well flow Pump level If A, B, or C, attach ADEC letter. ADEC water system number ~\.~\ FROM WELL LOG Wires properly protected~N) AT INSPECTION I SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot \\ Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ;On adjacent lots \Oc~t~ Public sewer manhole/cleanout ~'k'~,,b' Petroleum tank .,~.~ \4r, WATER SAMPLE RESULTS: Coliform ~ ~\~o ~ ~y-- Nitrate Date of sample: ~-/"' ~. ~' - ~ B. SEPTIC/HOLDING TANK DATA Date installed ~' "%\ ~ "[ ~' Cleanouts Y~N) k( High water alarm (Y/i~j~ Date of pumping Collected by: Tank size Other bacteria 17034 Eegle River Loop Read No. 204 Eagle River, Alaska 99577 Compartments Foundation cleanout ~(~N)'~/ Depressi~;~) Alarm tested '(Y/N)i ' Pumper '~'.J~.. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) onlot \\"~ To propertyline ~ c, Surface water/drainage On adjacent lots \ o ~\ ~ Foundation '~- o ~' Absorption field '~ [ Water main/service line \ C~ ~ '~' 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y~)'~ SEPA~ROM LIFT STATION TO: Wet'C~n lot On adjacent lots Man ufactu rer Manhole/Access (Y/N) ~ ~off" level at ~Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed ~"/'l~ ~ Length -~ °' ~ '~~ Width Total absorption area '~ L Depression over field (Y~) Results ~ail) Peroxide treatment (past 12 months) (V~ Soil rating \~c:~-\~5'O~¢'f~System type'~¢,~¢'~(--~-~ Gravel thickness ~ ~ Total depth Cleanouts present ~N) Date of adequacy test ~- ~ for ~ ~O ~ bedrooms es, eve Well on lot ~, t~~\~ To building foundation On adjacent lots ~c:~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots \ c> c> Property line \ ~-¢\ To e~xisting or abandoned system on lot ~,,~' Cutbank ~l ~ Water main/service line \ ~"~ Surface water \ Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effoct on the date of this inspection. $ & S ENGINEERING Signature 17034 Eagle River L~. ..... ~'""-' ·.%~,.,.- -~.4 Eagle River, Alaska 99572' Engineer's Name HAA Fee $ Date of Payment Receipt Number 72-026 fRev. 3/91 ) Back MOA Waiver Fee: $ Date of Payment Receipt Number WATER WEI~L ADVI~QRY HEA ,TH AUTHORitY A PROVAL During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Lot ~ Block / of /~~-~ ~'~" Subdivision, the well's productivity was determined to be O.~? gallons per minute. The minimum well productivity required by this department (AMC 15.55) for a ~/~ bedroom residence is ~;~ gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of noncritical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SFWER & WATER iNSPECTION AND REPORTS WELL INSPECTION g FLOW TEST SOIL TEST PERCOLATION 1EST STRUCTURAL & MECHANICAL INSPECTIONS WASTE WATER DISPOSAL SYSTEM ROBER] SHAFER, P E ROGERSHAFER PE ~ELL FLOW TEST D~TA CIVIL ENGINEERS (907) 694 2979 FAX 694 !211 LOCATION OF ~ (Legal Description)= ~ ~ ~ ~, ~o~ ~ DEPTHI ~ x CASING DEPTHt ~ TESTED BYI ~ ~ST D~: WIRES IN CONDUIT?,~ ORADIN.G, BACTERIA & NITRATE S---~-A~ES COLLECTED, RESULTSl ~.~.t. ~uaam~n.~ PaODUCES ~ ~PM W~H FLOW RATE NOT (~JARAh~p~-:t,--SUBSF~UBNT VARXATXONS CAN OCCUR! CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET Chemlab Ref.~ :93,1131-3 Client Sample ID :L3 81 ~TN. ~NOR Matrlx : WATER ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 Client Name Ordered By Project Name ProJect~ PWSID :S & S ENGINEERING Collected :03/18/93 @ 13:15 hrs. :RAY Received :03/19/93 @ 15:55 hrs. WORK Order :64212 : Report Completed :03/22/93 Tee}mieal Director ~}PH~ C,.EDE. Z :UA Released By :~{~~f.-~-- Sample Ren~rks: ROUTINE SABLE COLLECTED BY: RAY. QC Allowable Extract Analysis Parameter Results Qual. Units Method Limits Date Date Init .................................... ~.~ ~-~-~- _~-.~ ~ ..................................................................................... NITRATE-N ~ 0.92 / m~/1 EPA 353.2/300.0 10 03/22/93 LLH See Special Instructions Above UA" Unavailable See Sample Remarks Above NA - Not Analyzed Undetected, Reported value is the practical quantification limit. LT - Less Than Secondary dilution, GT - Greater Than MUNICIPALITY OF ANCHORAGE Department of Health & 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 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 3; Block I; Mountain Manor Subdivision Location (address or directions) Stillwater Drive (b) Property owner FIRST FEDERAL BANK Telephone: (home) Mai~i~j~8~Ce~Orthern Lights Boulevard, Anchorage, Alaska (c) Lending Institution Telephone 99503 Business Mailing Address (d) RealEstate Company and Agent RE/MAX OF EAGLE RIVER - A1 Romasz6wski Address 16600 Centerfield Drive, Suite 201, Ea~le River, Alaska 99577 Telephone 694-4200 (e) Mail the HAA to the following address: (or check here IXI, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING/694-2979 17034 Eagle River Loop Road, Suite 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Number of bedrooms Single-Family I~ 3. WATER SUPPLY Individual Well E~ Community [] Public [] Note: If.community well system, must have written confirmation from the State D. epartment of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [] 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 INFORMATICN ~ ' 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. 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 Telephone Address Date $ & S ENGINEERING 17034 I=agl~ River LOOp Road No. 204 Eagle River, Alaska 99577 6. DHHS APPROVAL Approved for ¢ bedrooms by Approved ~ 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 DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88)Back Page 2 of 2 ~ i.'~!M~UNICIPALITY OF ANCHORAGE (MOA) /,~,~,,*t-'~:~'' Heallh Authority Approval (HAA) · <~ CHECKLIST - FEBRUARY 1984 ,, "i~.',:~,'¢~' - , ¢.! 343-4744 A. WELL DATA Well Classification 3, ~ 1~. ~'f~ ,/Y~', lu Well Log Present (Y/N) 1 Date Completed .~,/~ Legal Description: ,/-..o'~ _2 } ~./OC.,('~' ..4l- If A, B, C, D.E.C. Approved (Y/N) 4~ Yield ( ~_-~ '- 8~) ' ~ Total Depth 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 Cased to ~_~ Depth of Grouting /_,oo Pump Set At L) ~ /c'~ ~' Sanitary Seal on Casing (Y/N) ? Depression Around Wellhead (Y/N) M ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Line /~//al To Nearest Public Sewer Cteanout/Manhole ~/~ To Nearest Sewer Service Line on Lot ~ ~ Water Sample Collected by ,~ ,~ ~----¢-~ff!'~d~m_.i/'~tg..~ ;Date /~. Water Sample Test Results ,~ ~ "/L~ _~.T~ c_.'~ F w ~ ~;:~,~ c-~,(' i dY Comments B. SEPTIC/HOLDING TANK DATA Date Installed 5-- :5t- ~¢B Size Standpipes (Y/N) ~ Air-tight Caps (Y/N) Depression over Tank (Y/N) fi) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) ~/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well ( f To Property Line ! (2 t~' To Water Main/Service Line ~' O "'~ To Stream, Pond, bake or Major Drainage Course No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped /-¢ - ~ ; for Temporary Holding Tank Permit (Y/N) 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 SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well / OO To Building Foundation ! (¢ Lot To Water Main/Service Line ! O" .'~ To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area _¢~ - / ~%'"Of/'~. Type of System Design l),~)?¢~J d~ Length of Field ~ O / ~ Depth of Field '~ ~ - Gravel Bed Thickness Z/_ f Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) lO0 't Comments D. LIFT STATION ~ Date Installed ~ Dimensions Size in Gallons "~ Manhole/Access (Y/N) "Pump On" Level at ~ 1%%. l'/~ "Pump Off" Level at High Water Alarm Level at f'~ "~ ~ Vent (Y/N) _ Tested for ~. Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) ~ Comments **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines inspection. Signed Company Date MOA No. $ & $ ENGINEERING 17034 Eagle River beep Road No. 204[ -"a~:. R!-;=r, A!~~ba 99577 Date of Payment Amount: $ 72-026 (Rev 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE,FEDERALALASKATAx ID #9951892-0040440TELEPHONE (907) 562-2343 ANALYSIS REPORT BY SAMPLE for Work Order # 18889 Date Report Printed: DEC 18 89 @ 14:01 Client Sample ID:L3 B1 MOUNTAIN ~ANOR S/D ?WSID :UA Collected DEC 15 89 @ 09:20 hrs. Received DEC 15 89 @ 16:15 hrs. Preserved with :AS REQUIRED Client Name : S & S ENGR Client Acct : SNSENGP P,O.$ NONE RECEIVED Req # Ordered By : BOB SH~FER Analysis Completed :DEC 18 89 Send Reports to: Laboratory Supervise5 :~TEPHEN C. EDE 1)S & S ENGR Special HOLD UPON COMPLETION FOR PICK UP. Instruct: Che~mlab Ref %: B932 Lab Smpl ID: 1 Matrix: WATER Allowable Parameter Tested Result Units Method Limits NITRATE-N 0.59 mg/1 EPA 353.2 10 Sample ROUTINE SAMPLE. SAMPLE COLLECTED BY Remarks: i Tests Performed See Special Instructions Above UA=Unavailable ND= None Detected "See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greater Than 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 (/)'~ '~ ~/ -,~- NAA# ~'~ ~',~ - ~)L/.~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 3, Block 1, Mountain Manor Location(addressordirections) Stillwater Drive (b) Property owner Cynthia Birklid Mailing Address 18512 Stillwater Dr. (c) Lending Institution ' Telephone: (home) Eaqle River, Alaska Telephone Mailing Address Business 99577 (d) Real Estate Company and Agent Target Realty- Dick Brown Address P.O. Box 774627 Eagle River, Alaska 99577 Telephone (e) Mail the HAA to the following address: (or check here I'~', if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 11034 Eagle R~ver Leop Road No. 204 Eagle River, Alaska 99577 TYPE OF RESIDENCE Number of bedrooms 4 Single-Family [] WATER SUPPLY Individual Well r~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. SEWAGE DISPOSAL On-site [] 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, I verify that my investigation of tills 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 Telephone Address Date S & $ ENGINEERING 17034 Eaa. le Rival Eagle River, Alaska 99577 6. DHHS APPROVAL Approved for ~ 'Approved ~ bedrooms by Disapproved Terms of Conditional Approval Conditional Date //~/~'~-,¢~/~/----//~,/~/?/?¢'~' 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. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev 7/88)Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: L~ A. WELL DATA Well Log Present (~/N) ";/' Date Completed Total Depth[~Ol9 Cased to ~o~ Depth of Grouting Static Water Level Casing Height Above Ground \~ Electrical Wiring in Conduit ~ii~ SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank .or~ Lot \ \"'~ To Nearest Edge of Ab'so~p~i:bn"F~i:~ld o~n Lot ', To Nearest Public Sewer Line ~//~' 'i To Nearest sewer Service Line on LOt; If A, B, C, D.E.C. Approved (Y/N) Yield Pump Set At Sanitary Seal on Casing ~)'N) y Depression Around Wellhead (Y/~I~ ; On Adjoining Lots ; On Adjoining Lots To.Nearest Public Sewer Cleanout/Manhole Water Sample Collected by ~/----'~ ~2¢-~--m I 'i,~ ~¢::~---~; Date ~-~ - ~ --~ Water Sample Test Results ~S¢~ ~ ~~. ~ ~~ B. SEPTIC/HOLDING TANK DATA Date Installed ~'"--~'~l- '~ Size Standpipes (~'N) 7 Depression over Tank (Y/~51~ Pumping/Maintenance Contact on File (Y/N) / Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: Air-tight Caps ~N) To Water-Supply Well To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course No. of Compartments y Foundation Cleanout ~N) // ate Last Pumped .Z~-~...~ 1"'3 ;for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field I Comments 72-026 (Rev. 7/88) Front Page 1 of 2 Square Feet of Absortion Area Depression over Field (Y~ Results of Last Adequacy Test C. ABSORPTION FIELD DATA Soils Rating in AbsorBtion Strata ~.<~ ~ ~,~-'~ ~///'~;~---- Type of System Design Date Installed ~'~/.../~~ ~ /~ ~ Length of Field Width of Field ~'~ ~ -- Depth of Field Gravel Bed Thickness ~ ~~ Stafndpipes Present~) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ~. ~ l~ To Property Line 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 \,~ ; On Adjoining Lots ~ IF' 10 t,.~ To Cutbac~ (if present) To Existing or Abandoned System on Comments D. LIFT STATION "Pump On" Level a~ Dimensions Manhole/Access (Y/N) High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Pumping~ **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 inspection. Signed Company Date MOA No. ~ & $ ENGINEERING 17034 Eagle River Loop Road No. 204 Receipt No. ~-~' c~(O 7~ ('"") , , '~/ (~ Date of Payment //0 '~,'~ --~ - ' Amount: $ //.~-- ~ 72-026 (Rev 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 )n tbe.~tate of this ,, 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ~ FEDERAL TAX ID # 92-0040440 Date R~pa[t Printed: OC~ 10 88 ~, 08:5,t Chent S~p[e [D~L3, B1 ~{OUNTAIN ~ANOR Collected OCT 4 88 Received OCT !i 88 ~ 14:00 hrs. Preserved with :NONE Ana!y~ls Completed :OCT 7 88 Chent Name : S & S ENGINEERING Client Aact : SNSENGP P,O,8 NONE REC'D Req ~ Ordered ~? ~ ~abo~atow 3uperv~soz :~TE?H~N C, EDE Se~d Repert~ to: Released By~ ~4~/~ .... ( .';~ I)S & $ ENGINEERING Instruct: Chemlab Raf ~: 2895 Lab Smpl ID: 3 Matrix: WATER Parameter Tes+~,d Renu Ai3 owabls lt/Units Method - , 'its 0,76 mE/1 ~PA 353.2 JO ~ample ROUTINE SAMPLE Tests Perforned ,)ee Special lnstruetion,~: /~b~:'¢e UA"Uhaval].z, bie Mon~ Det(~cted "See Sampl~ gamark~ Above MUNICIPALITY OF ANCHORAGE ~¢) ~ O DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) (b) (c) (d) Legal Description (include lot, block, ~,ubdivision, section, township, range) Location (address or directions) Properly Owner ~/¢~/~ ~-~24¢~ Lending Institution ~ ¢~¢. %.~¢~t¢~ Telephone Mailing Address Real Estate Company and Agent Address Telephone (e) Mail the HAA to the followinq address: or; Check if hold for pick up. List contact person and day phone number below. S .&~.~ENG!~EEi~NG 12054 7~ .,!. RI,ver Loop Road No. 204 Eagla River, Alaska TYPE OF RESIDENCE Single-Fa mily~rl~' Number of Bedrooms 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 OnsiteJ~ 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. Page 1 of 2 72 025 fRev 81861 Front 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, 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 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. 5 & S ENGINEERING Eagle River, Alaska 99577 Name of Firm Address Date Approved for ~.~ bedrooms by / Date Approved ~ Disapproved Conditional Terms of Conditional Approval CAUTION 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. Page 2 of 2 72-025 fRev 8/86} Back WELL DATA ,/2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHOFIITY APPROVAl_ (HAA) CHECKLIST _ FEBRUARY 1904 /") 264-4744 / Well Classification ___~]~..}_'~'2~.Q' ~_(~__O_.4/'~3~ .... If A. B. C. D. EC. Approved (Y/N) Well Log Present~.~_ Date Completed .-.-~-~-:.(.2Z~ _.. Yield v / , . t Total Depth_ ~;%~ased to ~_~ Depth of Orouting .... Static Water Level ¢'Z-' Pump Set At .... ~.'- Casing Height Above Ground ................. Samtaw Sea~ on Casin~Y)N) Electrfcal Wiring in ConduitS)N) ....... ~ .......... Depression Around Wellhead Separation Distances from Well: To Septic~ Tank on ~ot ........... ~_~% ............ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot __~%~2'__..; On Adjel ~ ng ets ........ To Nearest Public Sewer Line _ ~(~= ....... To Nearest Pubhc Sewer CloanouVManhole ..... ¢ (.~% ..... To Nearest Sewer Serwce Line on Lot Water Sample Collected oy '.~]~--~3, ~ ~=_~'~ ~. , Date .../__~ ~]- Water Sample Tkest Results _ ~~.~:~~_ =__ ~*.~ _~(c.t Comments ~ ~:~e_~.'zz_k _~...:~-~j;~ ...... - B. SEPTIC/ROL--D/NG TANK DATA Sta~dpipes(~N) ~L_~_. Au-tight Caps~)/N) _ x/ _ . Foundahon Cleanout~N) Depression over Tank (V/~ ........... ~-~ ......... ]._ D~te Last Pumped .... ~=~¢%.~ Pumping/M~intenance Contract on File (Y/N) , ~_ ..... ,/_' ....... : ~or Holding Tank High-Water Alarm (Y/N) __ ~/[k_ _ 7¢mporaw Hokt,ng 'lank Pe, m,t (Y/N) Separation Distances from Sepbc~ Tank: TO Water-Supply We,I ..... A_I_?<,. .... Z ........... 'FO Bu,ld,ng Foundation TqProperty Ltne ~.-- ........... re D~sposa Fm,d To Water Main/Service Line .(/O ~-~ ............... io Stream. Pond. Lake, or Major Drainage ' Course ...... ~__~ ~)C:, ~%~ ' Comments ._~~ .... ~:~- ;~ 'CZ~7~I ~3. P~ge"l of 2 72-026 fRev 8/861 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y~.I~ 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 Type of System Design Length of Field ,~,O / Depth of Field "~ Gravel Bed Thickness ~ Standpipes Present ¢~/N) ~'/' Date of Last Adequacy Test ~--~ '~-~-) ~ f~'~ To Property Line ~ ~7-~ ~ '"~ To Existing or Abandoned System on ; On Adjoining Lots ~ ~"J¢ To Cutbank .(if present) Comments Date Installed Size in "Pump On" Level at % High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ~- ~Vent (Y/N) pu~-rost. Meets MOA ** 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. Receipt .0. /~ 3 7 Date of Payment , _~---/~ ~'- Amount: $ /~ ~ ~O Page 2 of 2 72 026 (Rev 8/86/ Back CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~'° ~ FEDERAL TAX ID # 92-0040440 ~ J, i ;:1', t,