HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES #1 BLK 5 LT 12 Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ,'~'~.~ [~'"~"~-.-~¢~ PID Number: ~;) ,~"'":::;;~4~
Name:
Address: CJ~,J
LEGAL DESCRIPTION
Lot:
Township: Range:
WELL: [] New
] Se"ction:
[] Upgrade
;lassification (Private, A,B,C):
Driller:
Total Depth: ~se~To:
Ft. Ft.
Date Drilled: Static Water Level:
Ft.
Yield: / Pump Set at: ~Casing Height Above Ground:
GPM] Ft.~. Ft.
SEPARATION DISTANCES
From I ~"~ I Fled / Station I Tank l Sewer Lines
Sur,aCewater
Line _~ _
Curtain
Drain
Remarks:
.
Wastewater System: [] New ~ Upgrade
ABSORPTION F~ELD
[] Deep Trench ~hailowTrench [] Bed [] Mound [] Other
Soil Rating: ~' ~ GPD/Sq. Ft.
~epth to pipe boltom from original grade:
~"~! Ft.
Fill added above original grade:
~"~ eFt.
Gravel d,~l~t~: J&~t~'~l-J~ ~¢ Ft.
Total absorption are~ , /
Installer:
Total Depth from~iginal grade:
Gravel depth beneath I)ipe
Gravel length: ~ ~,,~ I~ Ft.J
Numb~rof lines: IDist:ncebetweenlines:
Pipe r'naterial~&~
Date installed:
_ I
TANK
N~Septic [] Holding [] S.T,E.P.
Manufacturer: ] Capacity in gallons:
Material: I Nember of Compartments:
"P'-~m~'---p on" level at: t~.P~m~-'~f-f~'~ la%el at: High water alarm
BENCH MARK
Inspections performed by:/~4~-~ ~~:)ates: lstJ0J~'~l~ J
Department of Hea~?n¢/Hu~an~ervices approval
Reviewed and approved by:~~ ~¢ '¢~_ Date'.////- ~- ~/
Location and Description:
72-013 (1/91) MOA 25
Permit No. ,~{~..~C~ I,~) -~,,, Page ~-' of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O, Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: _'~/..~C..¢_- ,¢~ ~ l",2..- PIDNo.: ~'~0~¢~.0~
4
72-013 A (2/9~) MOA 25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW910326
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:FEDERAL HOME LOAN MTG CORP
OWNER ADDRESS:15303 VENTURA BOULEVARD
SHERMAN OAKS, CALIFORNIA 91403
DATE ISSUED:10/09/91
EXPIRATION DATE:10/09/92
PARCEL ID:05066105
LEGAL DESCRIPTION: MOUNTAIN VALLEY ESTATES #1 BLK
5 LT 12
LOT SIZE: 71281 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
October 4, 1991
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& P LOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
Municipally of Anchorag
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Lot 12; Block 5; Mountain Valley Estates;
Request you issue a permit to upgrade the septic system serving the
referenced property and gra~ a waiver for the distance b~tween the
south property line and the existing seepage bed at approximately I ft.
The existing septic system was installed in 1983. An adequacy test
performed on the existing system by Tobben Spurkland, P.E. found the
absorption capacity of the existing system to be approximately 400
gallons p~r day.
The proposed drainfield upgrade is to be located on a slope of
approximately 35%, however, this is the o~y place on the property for
a system upgrade. We feel the thick organic layer of approximately 2
ft. will alleviate the possiblity of s~wag¢ surfa~ng which is usually
the concern with placing a l~achfield on steeper slopes.
There is a small drainage on the property as depicted on ouA site plan
which carries a small amount of wat¢~ from a cutbank created by the
driveway. Due to its minimal size and the fact that it dissipates i~o
the ground at a higher elevation than the septic system, we do not feel
this should be classified as a surface water source with a separation
requirement of 100 ft.
The property to the south is completely undeveloped with no apparent
plans of development in the near f~e which should allow the property
line waiver requested.
With the coming of winter conditions which shoed make this upgrade
nearly impossible due to the steepness of the lot, we ask that you
expedite your review.
If you have any questions, or require additional infermation for your
review, please contact us.
Sincerely,
ROGER J. SHAFER, P.E.
RJS/gm
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
Tom Fink,
Mayor
Niunicipality Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
October 10, 1991
Roger A. Shafer, P. E.
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject: Waiver Request for Lot 12 Block 5 Mountain Valley Estates
Waiver Request ~WR910049, PID ~050-661-05, SW910326
Dear Mr. Shafer:
Your request for waiver of the required 10 foot separation
between a septic system and a lot line has been approved. The
waived distance is 1 foot from the south property line to the
This approval applies to the existing septic system lot line
separation only. Any future upgrade to the septic system will
require all separations be met or another approval from this
department.
Sincerely,
Dani~th
Civil Engineer
On-site Services
Robert W. Robinson
Acting Program Manager
On-site Services
DJR/ljm
SCALE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION: ~'\~'
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
~ ~~ Township,
Range,
Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT d.'.'.'.'.'.'.'.'.~
DEPTH? ~ p
E
I
Depth to Water After4:~
Monitoring? Dale:
SITE PLAN
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE 19' "~ Im,nutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN__~ FT AND ~ FT
COMMENTS
R
ACCORDANGE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECTON ~HISDATE. DATE:
TttAT THIS TEST WAS PERFORMED IN
72-008 (Rev. 4/85)
(907) 279~9~6
Anita Bates
2~00 Cordova
Anchorage, Alaska 99~0~
SeptemOer 9, 1991.
Subject: Lot 12~ Block 5 Mountain Valley Estatm
Well. and Septic Inspe[:tion and Testing
Dear' Ms. Bates;
Per the verbal request o.~ Eva Lokken, ReMa~.~ of Eagle River~ we
in,pet%ed and tested the well and septic, system on Lot 12, Block
5 Mouu'~tair~ V~ll. ey E~-tate. The pur'po~e of the testing and inspec-'
tion was to obtain a Municipal Fle~alth Certi+icate for the proper-
The result o~ ou[r investiQati~)n is that the well meets
C~de requirement, bu'b, that the septic: system is not
properly and must be replaced.
Municipal
operation
According 'k¢~ Mrs, Lokk. en the d~elling has been vacant for a year
or more. The fact that the septic system had been unused for that
period requires that the system be pre charged with up to 2000
gallons of water before the actual test. The test itself con-
sist~s o~ adding a measurable amount o~ water to the absorption
field,~ r~cording i~ any wat~r accumulates in the field, and if
how much~ '~.he~n 'Lhe~ draining o~ the ~ield i5 monitored over a 24
hour period. This test procedur'o requires that access pipes
the septic tank and to the drain ~ield are available. On our
first visit to th~ ~i'te~ none o~ the pipes wer-~, ~ound. The
cords st the Health Department indicated that Doth the tank and
portions of the field were located under th~ parking area. After
~ome digging and probinQ the septic tank was found ~ith the
ar~cess pipes buried 6 inchms or more. The acce~s pip~ to
fi~].d were not rOLand. This n~.~cmssita'ked that pipes w~re
stalled. Th~s in+~rmat~n was +orwarded to you and permission
ext~md the access pipes for' tho septic tank and installing pipes
to the d~ain~ield was obtained.
On Septemb~er 5tl~ 1250 gallonss of water was~ add[.d to the drain
+ield. This was the required pr~.. charging. The addition o'~ this
water caused a water depth o.~ 12 inches to be measured in the
{ield, and a {low of wat~r into the trunk.
The next day an additional ;:.,~0 gallons of water was added to the
field at a rate o~ one gallon per minute. At the beginning of 'th~3
te~,t a water clep'L'.h o~ 9 inches w~s ma, asured. After adding the
,]~JO gallons water was again flowing back :into the tank~ and the
water depth in ti'ne field wa~ again 12 inche~.
24 hours lat,~tr- the wat(.~r depth in the ~ield was 'tCOClFId tO b~ 8.~
~nche~, This sh~ws that approximately 400 gallons o+ wat[~r had
b~en absorbed. The ming. mum ~'equirement for' a four bedroom house
SEP 11 '91 15:43 REMAX PROPERTIES
Lot 12 ~lock ~ ~ountain YaUey Es~a~e
P,3
is 600 ga],i~n~,
The we],l pr~duce, d ,t250 gallons in a 4 hour period. The .static
leYe~ was found ak z.%0 ~eet~ maximum drawd~wn ~as ~6 ~eet,~ and a
re.c~very ~ .50% ~as nrj'led in ~0 minu~es.
]'h~s ~y.~tem wa~ tested J,n tested and approved in 198,5. At that
time '~he is wa~ reported ~hat vehicie~ ,were. pz, rk~d or, 'top o~ the
absorptior~ ~ietd. It is possible that the compac.'tion caused by
ve, hicular tra{~icl ~ontr'ibuted to the {a'ilure of ~he system.
In order to evaluate the possibility of rmplacing the septic
system ~rJi 1 in.for'rnat, i or'~ mus'~ be ob~zai ned, a survey of ,~urf ~rze
water'~ and drainages must bm cot, duc[ed as wel~ as a topographical
survey, Lot l:Ln~s and '.~rJt ~r'ners must ~lso b~ local:ed. My ~e~
for this work is :~ 1,500.00~ The earl~,e~t I can start on this
~or'k w~).i be Oc'tobc~r 15th.
Please c~n-kact me. if additio¢~al ir~or'~latior~ is required.
T¢,~b ~F,
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF FIEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
82..5 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE ~-EW
% O ~,2- -r'~- ~.~. C~...u,~) p,,~ ~;.~'~~' E~ UPGRADE
MAILING AD D R ,ESS~-.~_
LEGAL DESCRIPTION \
LOCATION NO. OF BEDROOMS~,/.~J._.
Well __ ~ ? Absorption area ! Dwelling j~//~,,~ PERMIT NO.
~:~ I Manufacturer / '~'~ *~ ~ I Mate~ No, of compartments
~ Liq~c~c~ll°nsI IF HOMEMADE IInsi~ I~gth IWidth- Liquid depth
~ ~ I DISTANCE TO IWel A // I Dwelling PERMIT NO.
' I Material Liquid capacity in gallons
~ [ IWell J Foundation INearestlotlin~ PERMI-F~O.
~ [ DISTANCE TO: ~ ~/ /
~ ~ ~ / No. or u~, ] Length of each li~7 ] ~otal length of lines I Trench width Distance between lines
~ ~ ~ / J / ~ ~ I inches
~ [Top of tiloto finish 9rode / ~ Material boneoth tile i[~hos Total effective absorption area
u~ /kength~ t Width ~ t Depth/ ~ ~] / [~, ~. O/ ~ PERMITNO,
~ ~1~ / Type of crib Crib dia~ffeter Crib de~ Tbtal effective ~bsorption area /
~ ~ >, '. ~.V~ '
~ DISTA~ TO Bu~&n~ foundation Sewer line Septio tank Absorption area(s)'
OTHER
PIPEMATERIALS p F~,.~~
SOIL TEST RATING
INSTALLER
_
R EMAR KS
Permit ~
Applicant:
Department
825 ~ Street, Anchorage, AK. ~9501
264-4720
~/~ * * ~ HANDWRITTEN PERMIT ~ ~ ~
_ /WELL AND/OR ON-SITE SEWER PERMIT
MUNICIPALITY OF ANCHORAGE
f Health and Environmenta' ?rotection
Location: Phone Number:
Legal Description: ~0 ~' /~./~ ~~~ ~/ Lot Size:
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage BBd: Holding Tank:
Maximum Number of Bedrooms: .% Soil Rating(sq.ft/br) /~C3
The Required Size of the Soil Absorption System Is:
DEPTH I / LENGTH _ ~-'~ GRAVEL DEPTH ~/~¢~ WIDTH /0C:>/
The length dimension is the length(in feet) of Ehe t~e~ch br drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
~ ~ REQUIRED SEPTIC(HEH_-DTNG) TANK SIZE = /~ GALLONS ~ *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED ~ * ~
Backfilling of any system without final inspection and approval by this departmen~
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fee~
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31~ 1 9 ~ 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
t~esiden~s remodeled to include more t~ 3~roO?/ ~
Date: S~ ~-~ ~
qOI L5 LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
1
2
:3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
PERCOLATION
TEST
COMMENTS
SLOPE
SITE PLAN
ENCOUNTERED? ~ 0
/ I P
IF YES, AT WHAT _~' E
DEPTH?
/ / Gf~oss · Net Depth to Net
Reading Date Time Time Water Drop
/.
PERCOLATION RATE
TEST RUN BETWEEN
PERFORMED BY:
72-008 (6/79)
FT AND
(minutes/inch)
FT
1%/,~t~,~/~,.~ m
.].978
John ilopkins
Star Route 2 Box 9354
Ii',a¢/le t%iv~:r~ Alaska 99577
Subject:
~7~0351 lot 19 Block 3 Mountain Valley Estat¢;s
i)780971 Lot 13 Block 5 Mount~n/~n Valley Estat~}s
w~780936 Lot 12 BloGk 5 ~io].lntain Valley Estates
$780937 Lob 13 Block 5 F{ountain Valley Estat4~s
A per,nit i~suad by %his department for well and/or
P~rmits are issued on a oalen~lar year basis~ as stated
on the permit, by autherity of Muni~ipal ordinance.
If you ]lave dr.ille(:[ the ~:11~ a well lo~ should be
sent to I'~his d~par~3ment to docu~aent the installation
d. ate.
If there are any fuz"th¢~r ~g~estions, please contact
this office at 264-4720.
Sinoerely~
LeS N. Buchholz~ R.~.
Senior Environmental Specialist
enc~ copy of ~r~nit
PERMIT NO.
L:'EPFIRTMENT OF' ~EFII._'I"H FIND EN',,,'IRONMEN'['FIL
82::; '"L" ~.,TREET., FII'.~CHORRGE, f:lK. 99:3L.
FIPPL l CI::IN"f
LOCFIT I ON
LEaRL
JOHN L... HOPKIi"¥';;
JOHNN"r' DR
L:l, 2 E',5 MT VFtLLE¥ EL;;]' '~:.L
LO'I" ."-:;IZE '?±FZ:3:I. :~;E:!OFIRIE FEE"I
MtNJ. MUM I.)lb'I'FINCt~ E~E'I'HI-.'EN FI HELL FIND F:IN"r' ON--SITE iSEHF,3E DiSF'OSflL :~;'¢S'I'EM IS
.1aIC;'~ I:~'EET [':'OR: FI PRIVFITE HEL. L.~ OR
:L!:.,E~ IU ?.L4E~ FEE]' FROi"I 1:1 PI..IE:LIC: 1.4EI.L [:,Id.F'ENPli",[13 UPON ]'HE T'T'PE OF PUBI..IC [,.IELL.
H~LL LUBb Hh/..k RE~:!UIRt:'J.) FIND MU'.+5'I ~:E RETURNED TO THE [)EPFIRTr,IENT HITHIN
UF THE HEL.L [A]MPLETION.
O]'HER REQUIREMEN'f'L5 MFl't' FIPPL"r'. I;PEC:IFIE:FITION":; FIN[:, CON~;"I'P.'.UC:I ION [:,lFif3Rl:;tM2; I~I:;.'.E
H',,,'HiLRBLE TO iNSURE PROPER It'.IE;TFILLFrFION.
I C. ERTI F"¢ THF["I'
· 1: I I::IM FFIMILIRR 14ITH "file RE[.).UIREMENTS FOR ON-SI]'E 2;EHER2:; FIN[.', t.,IELL2; FIS 5;E'I"
FURI H h?'r' THE MUNICIPFII_IT"r' OF FINCHORFI~3E.
~: I ['fILL IN:"~;TFILL '['HE ';-';'-r".;:,]Er,1 lin FICE:OR[)FINCE HI'I'H ]'HE CODEE;.
WELL CONSTRUCTION LOG
'lh'
,tiller ~"_~.~ _t~?AdJF~._~____Type of ri8 ~r~ ~ .O~,e well com, leted !~'- ~ ~ ~
~ell location: (addresa & legal description) ~tTl~ ~1~ ~-- Loc,rich Sketch or remarks
Depth of well /0~ ft. Casirrg: depth /0~ _ft. dian,.
Static water level ~ .ft. (~bove,~) I~nd surface. D~te_~
Finish of well: (open-end, acreen, perlorated,~other)
Describe intervals and size:
for ~ hours with ~ __it, of drawdown from static level,
MUNICIPALITY
DEPT. ~:.
, ~ CTION
REDE/V
DRILLER'S MATERIAL LOG
Depth below land Give description of strata oenetrated
surface in feat (size o[ material, color, hardness of drillius, and water contant)
~"Otn 7~'""
.~ 6"-to
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE688-2759
OWNER OF LAND
ADDRESS
,'. - DEPTH OF WELL
LEGAL DESCRIPTION
DATE - Started t
PERMIT NUMBER
Ended /;'':" - ,,
STATIC LEVEL OF WATER FT. ~ .
DRAW DOWN FT.
GALS, PER HR '" :'
KIND OF CASING ., , r .
KIND OF FORMATION:
From ~ ; Ft. to ..~ Ft.
From ,.,,' Ft. to ) ? Ft.
From Ft. to Ft.
From ,i /; Ft. to ) r':~''
From Ft, to
From Ft, to
From __Ft, to
From__Ft. to.__Ft,
From Ft. to__Ft
From__Ft, to.__Ft,
From__Ft, to Ft
From Ft. to Ft,
From Ft, to Ft
From Ft, to__Ft,
From__Ft, to___Ft
From Ft, to Ft.
From Ft, to Ft
From__Ft. to Ft.
From__Ft, to_ __Ft..
From____Ft, to Ft
From__Ft. to__Ft
From .... Ft. to__Ft.
From Ft. to Ft.
From Ft. to Ft
From__Ft. to__Ft
From__Ft. to Ft
From__Ft. to Ft
From__Ft. to_ Ft
From Ft, to _Ft
From _Ft. to_ Ft
From Ft. to Ft
From____Ft. to Ft..
From Ft. to Ft.
From Ft. to _Ft
MISCL. INFORMATION:
DRILLER'S NAME
May 2, 1978
#77243
John L. Hopkins
Box 3021
~lchorage, Alaska
99508
Su~jeet ~ Permit Expiration
A permit issued by this department for well and/or on-site
sewer installation on Lot 12 Block 5 Mounta]a~. Valley Estates
Subdivision has expired since the issue date ~xceeds one('{.)
year.
In the event you still plan to install the well and/or
site sewer system, a new permit is required. The original
soil test may be usud to obtain a current pez~it.
If the well has been drilled, a well log should be sent
to this department to document the installation (late.
If you have any questions regarding the above matter, please
contact this office i~ediately at 264-4720.
Sincerely ~
Les N. Buchholz, R.S.
Senior Environmental Specialist
M I 1'.,] :1: MUM [:, ].' '.ii;]'F:lNCli]: i~ii:liE'l'HEIi~;:l'.,I FI I.,.IE'.t...I.... FIND
'.'L(!!I!?.I I::'l~i].-.'i:T F:'OI::~: Ft I::'I~:I',,,'I:::I"FI;~!: I.,.li]iiL. L.. Gl::::
I.,.IliEL. I_ L. Ol:]!iS I:::It:~i:E F-'.E:'(;!U];I:;.:I~i];) I:::11'.,1[:, I'"ll..l'.:.i;T
01:::' "r'HIE HEL..L. (]:i]iMi:.:'L.E]"Ii]iI'.,I.
:E;I::'E:(:::IFIC:I:::ITIOI'-,IS F:II'.,I[:, C:ONSTf:~:I.r. IC'T'IOI'.,I
I I",IS TI::IL L.F:IT I 01'.,1.
I CIFiI:Z?.'I" I l::'"r' 'T'HI::I'T
:1.: I I:::IM I:::I::IM I I_ I I:::ll:R I.,.I
F:'OI'R"r'H i~:'.~.' 'i"HE MIJKI I C ]; F'I::IL. I '1"¥ r3t::'
2.: I I.,.111...I.... IN:::i;'T'I:::II_I_ TItlE IZM I1'.,I
I'!::; 1::;0t:;7:.' .,I-'Ji!;I'I"E ii~li~].,lltiii]:;?zii; f:'tt'ql]i:, I.,.IIZLI....:!!; Fill::; :ii;l:}Yl"
I:::ff.,ICE I.,.1I 't'-I THE (;;ODE?';.
S I [iil'.,ll~EE):
FI l::' f:' l.., I C:I::tI",I'T ,JO HOF'I< I Iq'J!;
I :E::E:U[!!:[:, E:~
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. # o~-O Lct¢ [o¢'
1. GENERAL INFORMATION
Complete'legal description
Lot 12, Block 5, Mountain Valley Estates ~ f
Location.(site,ad,dress or directions)
NHN Johnny Drive
'~ropedy owner Sharon Jordon
~'Mailihg address po ~n~ 77]~R5, Eaq]~ R~ver, AK 99577
'~.Lending agency Premier Mortgage/Jody Clark Day phone 563-7795
Mailiqg address 3000 A Street, Suite 102, Anchoraqe, AK 99503
Agent Day phone
Address
Day phone 274-7443
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
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.
S & S ENGINEERING
Name of Firm ',7034 E=¢~- ~!ver L*?-2 Ro*_d No. ~_n4 Phone (~
Address Eagle River, Alaska 99577
Engineer's signature ~/[¢-/~('~ ~/~/'~ ~- Date
DHHS SIGNATURE
l,,// Approved for F'
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with th-e following stipulations:
Additional Comments
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 ) Back MOA #21
Legal Description:
A, WELL DATA
Well type
Log presenl~N)
Total depth
Sanitary seal ~)
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform O
Municipality of Anchorage R
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907.) 1~Si4F~Ciy of Anchoraqe
uept. Health & Human SerViCes
Health Authority Approval Checklist
~' ~ ~V-~¢ ~'~ Parcel I.D.:
Date completed
Cased to / O C_~ I
If A, B, or C, attach ADEC letter. ADEC water system number
Casing height (above ground)
Wires properly protected ~4)
FROM WELL LOG AT INSPECTION
I'Z~' g.p.m. ¢, 2
Date of sample: ¢///J"//¢1 ,¢
g.p.m.
Nitrate
O. ~/~- ~ Other bacteria O
Collected by:
B, SEPTIC/HOLDING TANK DATA
Date installed ~!/~'% Tank size I'7-~;r''c, Number of Compartments CZ.~ Cleanouts ~N)__,~_
Foundation cle~.nou~N) ~/ Depression
Pumper
Date of ~PUmping 0/:"~''''.c;1~::
C. ABSORPTION FIELD DATA
Date installed ~.~,~'i I Soil rating (g.p.d./fForft2/bdrm) ¢,~/7~'~_-_-_-_-_-_-_-_-_-2Systemtype D/~/~,~.,%~OD__
Length"~ ~/t,/5''- &' Width ,2~ /'//~ / Gravel thickness below pipe O~ ;> ..,/.~ _ Total depth
,/
Effective absorption area [e I L- Monitoring Tube present (..~VN)_(~ Depression over field (Y~
Date of adequacy test ~"/,¢'"'~ ~ Results ((E~Fail) -~AP~J For ~ bedrooms
Fluid depth in absorption field before test (in.); ¢ ' Immediately after ~,~'* gal, water added (in.):
Fluid depth ~ (ins) Minutes later: ~ Absorption rate = &o ~ g.p.d.
Peroxide treatment (past 12 months) (Y~ ./O¢/a~ //--/¢nt.,o/t) If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pump on" level at* ~vel at*
*Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots I, o~.~ ~''F
On adjacent lots
Public sewer manhole/cleanout tO Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation .i'?--I ~ Property line I,~ ~'~ Absorption field
Water main/service line lc:' \~ Surface wateddrainage (.C:~ ~.k- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~ I \~V~ ~b Building foundation ~-'l~ t k
~ Water main/service line
Surface water \c.~ c~ \"+ Driveway, parking/vehicle storage area
Curtain drain ~ l~ Wells on adjacent lots '~'~'"'°
I certify that I have determined thru field inspections and review of Municipal rec ~ms are
inconformancewit70//~2~g esineffectonthisdate. /.~?~'_
Signature /'~/~'/~'~' '~/~ ~, ~'h' ~ ,~ ~
HAA Fee $ '"~ ~'~' ~
Receipt Number ,Z.///~'O ("-¢/7/0/
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
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
/-¢,/'~ O ~J HAA#. ~ ~C~ \ (-~,z~2~,(")
1. GENERAL INFORMATION
Complete legal description
Lot 12; Block 5; Mountain Valley Estates #I
Location (site add'ress or directions)
Property owner
Mailing address
NHN Johnny vriv¢
Day phone
15303 V~ntura Blvd. ~ Sherman Oaks ~ Calif. 91403
Lending agency
Day phone
Mailing address
Agent A~Lta Bates RE/MAX PROPERTIES
Address 2600 Cordova Avenue Anchorage,
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
XX
Day phone 276-2761
AlaSka 99503
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
XX
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
NOTE:
72-025 (Rev. 1/91) Front MOA #21
m, uawwoo leUOR!pPV
:suo!;elndp, s 6U!MOIIOJ eqj q),!M 'SLUOOJpeq
Joj leAoJdde leUOpjpuoo
'peAoJdd~s!a
'suuooJpeq
~oJ peAoJddv ~
a~ln±VNglS SHHO
euoqd
'uoi~oedsu! s!ql to m, ep eql uo ~oe~te u! suo!~elnBeJ pue 'seoueu!pJo
'sepoo e~m,S pue led!o!UnlAI lie LI),!~ eoue!ldLUoO u! si' uJe~,s/~s lesOds!p ~e~e~e~se~ Jo/pul~ 41ddns
~e~,eM mjs-uo ell1 'uop, oedsu! pue uo!3eBp, se^u! X~u Luo~t pue Sel!¢ eBeJoLtoU¥ ¢o ~),!led!o!un~ eLp,
UUO~J peu!e~qo uop, eLuJotu! eql uo peseq leq~ ~tpe^¢eqpn~ I 'u!e~eq pe3eo!pu! e~nlonJ~s to edAl pue
SLUOO~peq ~O Jeq~unu eq~ ~ot elenbepe pue leUO!~oun¢ 'eles s! Lue~s~S leSOds!p ~ele~e~se~ ~o/pue
~lddns ~eleM e)js-uo eLp, ~,eLI1 S~OqS uo!leo!ldde le^o~ddv ~poqlnV Ll~leeH S!LI~ tO uop, eB!lseAu!
X~u ~,eq~ X,t!Je^ I 'MOleq UMOHS e),~p uoReP!leA eq~ ~o se pue o),eJeq p@x!~e I~es XLU Xq pe!J!lJeo s¥
'9
EFt=INIIDN;B AG NOIJ, O~dSNI -lO J.N=IIN=IJ2¢.I.S 'g
Legal Description:
A. WELL DATA
Well type '~
Log present~N)
Total depth / E2("¢~'
Sanitary seal ¢~N) _ ~
Date of test
Static water level
Well flow
Pump level
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
If A, B, or C, attach ADEC letter. ADEC water system number
"'/ I Date completed /~;;~ ~ ~'-~E~ Driller
Cased to / ~ Casing height
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
t
Septic/holding tank on lot ~ ~
Absorption field on lot \ ~ ~1
Public sewer main ~-~
Sewer service line "'~-~ I ,.~
Wires properly protected~)
g.p.m.
MLINICIPALI'fY OF ANCHORAGE
AT INSPECTI(~/iRONMENTAL SERVICES DIViSiON
f,~0V 0 4 1991
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank "~ IR-'
WATER SAMPLE RESULTS:
Coliform ~ ~¢~-/~-¢' ~ Nitrate
Date of sample: J ~ ~ ~--~ ~ '¢~ I
B. SEPTIC/HOLDING TAN~ DATA
Date installed
Cleanout~¢¢~)
High water alarm (Y/N)
Date of pumping
C;~' ¢~"~ /~/ Other bacteria
Collected by: ~'¢~' ~
Tank size \"~..~L~ Compartments
Foundation cleanout ~4) '"/' Depression
Alarm tested (Y/N)
~ '¢~1 Pumper ~/-_-_-_-_-_-_-_-_-~ t~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
~..~
Well(s) on lot [ ~ On adjacent lots
To property line I L~I
Surface water/drainage
72-026 (Rev, 7/9~) Fron! CONTINUED ON BACK PAGE
C. LIFT STATION
Date i n stalled'"'"'~
Size in gallons
Vent (Y/N) "Pump on" level at - -
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
D. ABSORPTION FIELD DATA
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Surface water
Date installed ~ I¢- '7~-'2~.~ t , Soil rating'¢'~ d~,~¢~. ¢~¢¢~z.- System
~ ' ~' Totaldepth ~1~
' ~ ~ ~ Gravel thickness ~,~ ~
Length ~ ~Width ¢~
Total absorption area ~ ~ ~ Cleanouts present. N)
Depression over field (y~ ~ Date of adequacy test
Results (pass/fail) ~ %~ ~¢E~¢ ~ ~ for ~ bedrooms
Peroxide treatment (past 12 months) (Y~ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots-- ~c:?
!
Surface water / ~ Driveway, parking/vehicle storage area
Curtain drain lx~rTN~ ~.~t5>~: .~d
E. ENGINEER'S CERTIFICATION ~ ~--¢~¢~6.,.
I
On adjacent lots /~ ¢? Property line
T¢ existing or abandoned system on lot
Cutbank I'~¢~ Water main/service line
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
$ & $ ENGINEERING
Signature , ~.....A ~_..,~ ,~: ....
NamE~gb ~iYer, Alaska
Engineer's
Date [[ ~ ~
HAA Fee $ /?¢ ~
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Back MOA 21
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CFRTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date JU~Le.__2Z,.,~L..,~I 995
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 12 Block 5 Mountain Valley. Estates #1 Subdiv~sion
Location (address or directions)
T14N R1W Section 33 Hi_ghland Road
(b) Applicant Name Robertson Telephone: Home _694-5069
Applicant Address _~_o_h~y~e~gg!e Riv ~ 99577
(c) Applicant is (check one): Lending Institution []; Owner/buiLder ~; Buyer []; Other [] (explain);
Business R/A
(d) Lending Institution Merrill Ly_nc_h Re_locc_t~_rL _ Telephone ~/A
Address ~10,9_0__0 NE 4th $ui~200 PzC~%lLiew Wash~~04
(e) Real Estate Company and Agent F~~~ R~I ty
Address ~0]~o~ Li~~, ~.hnr~a Al4 9~503
Telephone 279-76~
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [~ Multi-Family []
Number of Bedrooms ~_) Four
Other
WATER SUPPLY
Individual Well~ Community D Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite I~ 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 (11t84)
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 ware! 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 Eaglet Ri_ver Engineering Services Telephone ___694-51~_5
Address P,Oo Box 773294, Eagler giver AK 9~577
Date
This Department has received written confirmation from the engineer
(Lou Butera) regarding the conditional of June 26, 1985. It has now been
completed and this property now meets municipal codes.
Engineer's Seal
DHEP APPROVAL
Approved for (4)
Approved ~×
Disapproved _ Conditior
Terms of Conditional Approval
CAUTION
'l'he 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 DHE-'P 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)
I hereby certify that I have s t'w,Vcd thc loth)wing
Aaehorage lleeording Prccinct, Alaska, arm tha~ tb.e impt'ove~
nqmd~ situated tirol:eon are within the property liner; and do
:, ~ (~verlnp or eueroaeh on the property lying adjacent them-.
b,. that no improv(mmnts ,m property lying
e~mach on the premises in question anti that there are no
roadwsys, transmisMoa line'; or other visible easementf; Gu
s~id property except aa indicated hereon.
Dated rd Eagle l~iver, Alaska
IO;)BI¢IiT C JOHNSON
':, ,~,l,~l: Hegistered Land Surveyor No aSO-I.,S
?,C:c Box 456, Eagle lurer, Alaska
Phone (90?) 69'~
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
Application Date __
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
_~ t~ I ,~ ~/~¢~ ~ /.~?~,.~ ~,,~ ~/~ //~>. /-:~'/~, ~ ~/
Location (address or directions)
Applicant Name ~ ~ ~ ~'~ ~ Telephone: Home ~ ~"~a~ ~ Business ~_
Applicant Address __ ~ ~ ~ ~.~ ~_ ~ c~ -~ ~f~ ~?
Applicant is (check one): Lending Institution ~; Ownedbuilder~; Buyer ~; Other ~ (explain);
(d) Lending institution /)'~¢rr-,'//
Address /~ ¢~ ~ ~
(e) Real Estate Company and Agent
Address
(f)
Telephone --~ ~¢ '- ~//
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family,[~ Multi-Family []
Number of Bedrooms .~_
Other
WATER SUPPLY
Individual WellX Community [] Public [2
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.
Page 1 of 2 72 o25¢~ 84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
Az oerlified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
AulhorJty 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 lhe Municipality:f0~ Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is,!n compliance with all Municipal and State codes, ordinances, and regulations in effect on
they"date of this inspection.
Name of Firm ~EJ~LF,~.~ Telephone
EAGLE I~IVER, AK 99§77
Address PY0.-B0X773294
Date ~94-§195_
Engineer's Seal
DHEP APPROVAL ..., -x/,._.,~/ ~,
Approved ........... DisapF)rov~- Oondi~ional
T~rrn~ of Cond~[~ocal Approval __- ;-
2) ' '2 ~ ,' '~ ~ ~ /
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 tho State oI Alaska. The DFIEP does tills as a courtesy to purchasers of homes and their lending
ir,~.tJtulions 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 omission~.i/~/~e
Page ~ of 2 I ~ '(/> (' ~ ~
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description: ~.o ~'-
IvlUNICIPALhTY OF
DEPT. OF
I]NVIRONMENT/~ PRE
Date Completed /o/? ~ Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
Well Classification
Well Log Present (Y/N)
Total Depth //~'- / 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
Cleanout/Manhole ./'//o ~,
Water Sample Collected by ~,..¢¢
Water Sample Test Results
Comments
If A, B, C, D.E.C. Approved (Y/N)
Y
; On Adjoining Lots /~-~o '~-
?~,0 ¢ ; On Adjoining Lots
· To Nearest Public Sewer'
To Nearest Sewer Service Line on Lot ,~_
;Date
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) _ Y Air-tight Caps (Y/N)
Depression over Tank (Y/N) /V/
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well /Oo +
To Property Line /O C-
To Water Main/Service Line /¢
Course //.-/o>~ 1~
Size /¢'g" '~-0 No. of Compartments
Foundation Cleanout (Y/N) '
Date Last Pumped ,.7~,,~
_; for --
Temporary Holding Tank Permit (Y/N)
To Building Foundation /d'" '"
TO Disposal Field '--~"
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026tllt84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of
Type of System Design
Length of'~:f
Depth of Field
Square Feet of Absorption Area ~' / ~
Depression over Field (Y/N) N
Results of Last Adequacy Test ,,~e~
Separation Distance from Absorption Field:
To Water-Supply Well ,/f2o f-
To Building Foundation 3o /
Lot ,/6-"z_n~ ~,~
Gravel Bed Thickness -
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line /o ~'-
To Existing or Abandoned System on
; On Adjoining Lots
To Water Main/Service Line /o ¢- To Cutbank (if present) Z/.~,~ .e_
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~----,,,¢ ,~ ,h" ~-~ .~ ~4' ,Z~_,4
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
Receipt No.
Date of Payment
Amount: $
** 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 -~,~.Z~ ,z~ ~'-,~j.-~,~,¢~-.,.~- MOA No.
Page 2 of 2
72-026 (11/84)
APPLIC, IT FILLS OUT UPPER HAL ONLY
/-~ /¢¢)/~4~ .... . ., ~ ._
Realty Co. & Agent
Address
Legal Description
Street Locati~
Type of R~dence
~gle Family
~ Multiple Family No. of Bedrooms
~ Other
Phone
Phone
Wa~t er S~ic~fy
L/}~lndividual
[] Community
[] Public Utility
L,&/fndlvld ual
[] Public Utility
[] Holding 'rank
ATTACH WELL LOG. A well Icg is required for all wells drilled since Juee 1975.
For wells drilled prior to that date, give well depth (attach Icg if available).
Year Individual nsta led:: 7('t~ :).,~") ,w
When Connected to Pub,lc Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Date
Inspector
Field Notes:
Time
Date
Inspector
Time
Date
Inspector
Time
Date
Insp:o.r
] %-APP,OVEO ~OBOO~S
i O,SAPPROVED
CONDITIONAL APPROVAL'
[)ATE
'CONDITIONS OF APPROVAL
Soils Rating
72.023 (3182)
Date Sewer Instal, eft
Well TO Absorption Area
Well to Tank
Well Log Received