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HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES #1 BLK 5 LT 14 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 NAME )_'~ MAILING ADDi~SS/") ~ __// j / LOCATION [ Well. ~ / ~ Absorption area,/,~ ~ ~ I [ ' I ~: ~ Manufacturer ~ ~ .. ~ DISTANCE/~TO' Well / ) / Dwelling ~ Manufacturer -- ~ I '-- I Well Foundat on ~z IDISTANCE TO: I f ] ~ ~ ~ I No, of lines I Length~ac~li~ Total lengtb of lines -~ I I II ~ ~  Top of tile to finish grade / Material beneath tile , Length ~// ( Width ,~ ~ / D~th( ~ · I Type of crib Crib dJamete~ Crib Driller ~ I Building foundation Sewer line DISTANCE TO IPHON~ ~;~'NEW [~]UPGRADE / Width ' Material Nearestlotline Trench w dt~ hlches inches NO, OF BEDROO~_IV~ No. of compa~ents Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance between lines Total effective absorption area ERMIT NO .... Nearest lot Ii~e,.~'.--,'~_~ / /.._/,/~ Distance to lot line Septic tank OTHER PIPE MATERIALS 8OI L TEST RAT~G ~ /ob R EMAR KS .~- .I -013 (Rev. 3/78} DATE PERMIT NO. Absorption area(s) 0 0 0 0 C) 0 0 0 0 0 0 ~ [- ~ k~ F-, [-' ~ I-' I-' i-, k~ 0 0 © 0 © 0 0 0 0 0 (D LOt *!3 ~ J?et-.e.t:s C,/C;<.N: .::u!d Lot .Id ~ Si. oeP: '~'~ ' J. 96X i:;;:~ g 1 e River 9957't Department MUNICIPALITY OF ANCHORAGE ~ Health and Environmenta~ ~rotection /~//v~ 825L Street, Anchorage, AK. ~9501 264-4720 Permit ~ Location * * * HANDWRITTEN PERMIT * * * Wm.~LJ~ AND{~!~[ ON-SITE SEWER PERMITC~ ~/~ Phone Number: _ Legal Description: ~ ~y Lot Size: ~ype of Soil Absorption 'System Is: Trench: Drainfield: _ Seepage Bed: /~ Holding Tank:_,~_r_- Maximum Number of Bedrooms: L.~ Soil Rating(sq.'ft/br) The Required Size of the Soil Absorpt~gn Syptem Is: DEPTH LENGTH ~.~. GRAVEL DEPTH ~OML/ WIDTH ~he length dimension is the length(in feet) of the trench or drainfield. ~he depth of a trench or ~it is the distance between the surface of the ground and the bottom of the e×ca~ation(in feet). ~here is no set width for trenches. ?he gravel depth is the minimum depth of gravel between the outfall ~ipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE GALLONS Permit applicant has the responsibility to inform this depar~men~ during ~he 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 department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet 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 8 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 wi/~nstall the system in accordance with codes. (3) I~de~s~nd that tj~e on-site sewer system may require enlargement if ~he r~~e is~mod~led to include more that 3 bedrooms., plicant - J/ ' ~-/---~' Date: /~///~/~ U SWP/024 (1/81) SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: LEGALDESCRIPTION: L /'~" 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15- 16- 17- 18.- 19 2O DATE PERFORMED: COMMENTS [] PERCOLATION TEST WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SITE PL /'7 "" Gross Net Depth to Net Reading Date Time Time Water Drop ~ ~ E~ ~:'~(~INV-.~RIN~ PEREORMED By: ...... ~R~ 1~ 72-008 (6/79) PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN .- AND ---- FT CERTIFIE~~/~" MUNICIPALITY OF ANCHORAGE Department of Health & Human Services r)IVISlON 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 ~,_~'~'~- ~. I -~)'~ NAA Cf 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) , '? / -~'% ..~ . , . -~/ ..... (b) Property owner Mailing Address (c) Lending Institution Location (address or directions) ,/~'~. ' ] d '~-~, _~,.:--¢x ~.,.~'~ ~'~ /elepnone: (home) Business Telephone Mailing Address (d) (e) Real Estate Company and Agent Telephone Mail the HAA to the following address: (or check here,~,-if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING ~le River, Alaska 995~ 2. TYPE OF RESIDENCE Single-Family'~¢~ Number of bedrooms 3. WATER SUPPLY Well ~' Community [] Public [] Individual 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 [] 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 '>tJo~ s,J@@U!~Ue leUO!SSe~oJd eq~ u! SUO!$S!LUO JO S JO J J@ JO~. elq!suodseJ )ou s! e~eJoqou¥' jo/q!led!o!unW eq/'penss! s! e~o)j!iJeO e eJojeq ~ep ez/~18u9 Jo suoRoedsu! ~onpuoo ~ou op SHHQ jo see~old~ui3 's~ue~ueJ!nbeJ e~e3s pue leJepej u!e3Jeo ,~sp, es o~ Jap Jo u! 5u!puel J!eq~ pus SeLUOq JO sJeseqoJnd o], /~se~,Jnoo ~ s~ s!q~ seop SHHQ eq.L 'e>JSSl¥ jo ele~,S eq~ u! peJe~S!beJ Jeeu!6ue leUO!SSejoJd ~uepuedepu! ue,~q eAoq8 S qdeJ§e~ed u! ue^!b suop, e~ueseJdeJ eql uodn ~lUO peseq pe3eo!~!JeO leAoJdd¥ ~[JOq~,nv q~,18eH senss! (SHHQ) seo!^JeS u~uJnH pue q~l~eH ,to ~ueu4Jedec] e6eJoqguv jo ,~!l~d!o!unv~ eq.L pe^o~ddes!O leUOp,!puoo leAoJddv leuo!~!puoo ~o SLUJe.L ~. peAoJdd¥ ~C Jo,t pe^oJddv =IVAOEIddV SHHO '9 euoqdele£ sseJpp¥ t.uJ!=l ,~o eWeN ?~.~ ~xOx~ ~,.~,x~ MUNICIPALITY OF ANCHORAGE (MOA) ~ ,.,<~ ~*'~'.~r,,~j~"~,~ Health Aulhority Approval (HAA) ~ CHECKUST- FEBRUAR ~ W~W ~ 343-4744 ~ ~.~O .~ ,q~ Legal Description: ~ [~[~ A. WELL DATA ~ Well Classification t~J ~O~ If A, B, C, D.E.C. Approved (Y/N) ~/~ Well Log Present ~N~ ~ Date Completed ~ ~ ~ ~- ~ Total Depth ~l~ ~ Casedto_ ~[/ Depth of Grouting Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (~'q) V SFPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot Yield '¢~',~ 6Ft'''l "~ Pump Set At OX-, Sanitary Seal on Casing C~N) "/ Depression Around Wellhead (Y/(~' ~ To Nearest Edge of Absorption Field onLot \ \ To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by ~. ~'~ ~-~:~l~(-~,l;Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes(C~'N) "-/' Air-tight Caps ~Z~/N) Depression over Tank (Y/:r4~ Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) r-'~/f~ No, of Compartments ¥ Foundation Cleanout~[~YN) · Date Last Pumped ; for r,~/,/~ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well \ To Stream, Pond, Lake or Major Drainage Course Comments To Property Line To Water Main/Service Line To Building Foundation (,~'~ To Disposal Field ~-- 72-026 (Rev. 7/88) Fronl Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata t, ~--~?/¢¢b'~ Date Installed / ~ ~ ~ ~ ~;~"~ Width of Field ~ ~ Square Feet of Absortion Area Depression over Field (Y/::~¢~ Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness I.~ ~:~"¢=' Statndpipes Present ¢5~N) I'--k Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundatio~ Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area V \ t ~;:,1 To Property Line ,¢yr::, ~ c~ ~...~ To Existing or Abandoned System on ; On Adjoining Lots "'"~"~'c:~ I"'~ \. c::~-J¢~ To Cutback (if present) Comments D. LIFT STATION ~ Date Installed "Pump On" Level at'~F~ 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 gu~dehnes in effec~,~~ fi, of th~s '. inspection. Signed S & $ ENGINEERING 17034 Eagle Ri,er Loop go.d NO. 204 Date of Payment O'~ ~ Waiver Fee: $ Amount: $ / ~/~ ~ O Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICA L LABORATORIES OF ALASKA, INC. ANALYSIS REPORT BY SAMPLE for Work Order # 13408 Date Report Printed: MAY 25 89 @ 09:32 Client Sample ID:Li4, B5 ~ VALLEY EST. PWSID :UA Collected MAY 17 89 @ hrs. Received MAY ].8 89 @ 12:30 hrs. Preserved with :AS REQUIRED Client Nome : S & S ENGR Client Acct : SNSENGP P.O.~ NONE REC'D Req $ Ordered By : Analysie Completed :MAY 19 89 Laboratory Supe{v~33:~_DRTZPNEN C. EDE / Send Reports to: 1)S & S ENGR 2) Special Instruct: Chemlab Ref #: 5335 Lab Smpl ID: 1 Matrix: WATER Allowable Paramete= Tested Result/Unite Method Limits NITRATE-N 0.25 mE/1 gPA 353.2 10 Somple ROUTINE SAMPLE, Remarks: SAMPLE COLLECTED BY ESS. 1 Tests Per£ozmed ' See Special Inet~uctions Above UA~Unovailable ND= None Detected '* See Sample Remarks Above NA= Not Analyzed LT=Less Then, GT-Greate~: Then 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) Legal Description (include lot, block, subdivision, section, towr~ship, range) Location (address or directions) (b) Applicant Name _1~.¢--(=::t-~' ~.J/,~'l.~/:~ Telephone: Home Applicant Address Business (c) Applicant is (check one): Lending Institution []; Owner/builder,~ Buyer []; Other [] (explain); (d) Lending lnstitution I'¢~ Address ~----~;~_ ~.~.- (e) Real Estate Company and Agent Address Telephone' ~ (f) ~the HAA to the following address: Telephone TYPE OF RESIDENCE Single-Family,'E~-- Multi-Family [] Number of Bedrooms '~ 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 Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 ~ jo ~ ~bed ')tJO~ s. Jeeu!bue leUO!SSejoJd eq) u! SUO!SS!LUO JO SJOJJe JOJ elq!suods@J ~ou s! eeeJoqouv jo XHled)o!unR eq_L 'penss! s! e)eo!J!Peo e aJojeq elep ez,~leue JO suo!]oedeu! ~onpuoo leu op d~iH(3 1o seeXoldcU3 's~ueLueJ!nbeJ e~els pue leJepeJ u!ep@o/~s!ies o~ JepJo u! suo!~nl!~su! 8u!puel ~!eq~ pue seuJoq jo sJeseqeJnd o1 Xs@pno3 e se s!q), seep d~]HC] eq/'e;tselV ,to a~elS eq~ u! peJe~sieeJ Jeeu!eue leUO!SSa,toJd ~uepuedepu! ue ,~q e^oqe ~ tldeJ§eJed u! ua^!8 suo!~e~ueseJdeJ eqi uodn ~lelO$ peseq selee!i!~eo le^oJddv /~!Joqlnv qileaH senss! (d3HQ) uo!loe~oJd le~UeLUuoJ!^U:l puc q~leeH jo lUeLupedeQ e6eJoqouv ,to ,~l!led!ounv~ eqj. NOli~¥O leUO!~!puoo pe^oJddes!G '9 euoqdela± uo hoe,ge u! suo!~elneeJ pue '$eoueu!pJo 'sepoo e~e~S pue led!o!unR lie H~!M eoU~!ldLUoo Jo/pue ~lddns Jele~ e1!s-uo eq~ 'uo!~oadsu! pue uo!iee!~saAu! X~ ~oJ~ pue Sel!~ abeJoqauv jo X~iled!o!unR eql ~oJl pau!e~qo uoi~e~JOjU! eq~ uo paseq ~eq~ XjpeA JeqUnJ I 'ufeJeq pa~eo!pu! aJnlonJ~s ~o ed~ pue s~ooJpaq ~o Jeq~nu eq1Jo~ e~enbape pue leUO!~ounl 'e~es sf ~e~s~s lesodsip Je~e~a~se~ JO/pue Xlddns Je~e~ a~!s-uo q~leeH s!ql jo uo!leb!~seAu! X~ ~eq~ ~j!JeA I '~oleq u~oqs elep uo!~ep!leA eq~ NOI~Y~OJNI aNY v~va 'HOaYaS 311J 'SIS31 'SNOI2D~dSNI 9NIOIAO~d ~BIJ 'S MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION J U L ! 6 ]987 RECEIVED Well Classification MUNICIPALITY OF ANCHORAGE (MO~l HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal De.scription: If A, B, C, D.E.C. Approved (Y/N) ~/,~ Well Log Present ~N) Total Depth ~:)j I Cased to ~:~1 / V Static Water Level .~ I /../L Ii Casing Height Above Ground Electrical Wiring in ConduitS) Separation Distances from Well: To Septic/.Metdfrr9 Tank on Lot Date Completed __ /O -/~ ~ Depth of Grouting Pump Set At Sanitary Seal on Casing~:~N) Depression Around Wellhead (Y~ /~O / '/" ; On Adjoining Lots / ,O¢ /'-/- To Nearest Edge of Absorption Field on Lo) //¢ ' ; On Adjoining Lots /DO g- To Nearest Public Sewer Liner3~ /'J/ct To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ~?~-~ ~L Water Sample Collected by ~ ¢ ~/~~ ;Date ?~?~7 Water Sample Test Results ~~~ ~ ¢[~~ '~~~ Comments ~ ~ ~¢ ~ ~b~ ~ ~ ~ B. SEPTIC~TANK DATA Date Installed Standpipes (~/N) Air~tight Caps Depression over Tank (Y,t~ Pumping/Maintenance Contract on File (Y/N),j / Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic,4~ Tank: Size / ¢24:~.P No. of Compartments ~- Foundation Cleanout(~)N) /,..~//~ Date Last Pumped. 7~- ~7 ; for - Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line Course Comments ~"7~, To Building Foundation ('07 ~' To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026(11184) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata / ..,<-~:~ ,.)b//..~,¢.... Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y~) Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ? ! ~ / Type of System Design Length of Field ~ / / Depth of Field . Gravel Bed Thickness ~ ~:)~/U /~ Standpipes Present ~/N) Lot To Water Main/Service Line / o ~ '~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots '"'~/"'/'' To Cutbank (if present) /~J./~ Comments 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 ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to alIM/OA a~l. HAA guidelines Si ned S & S ENGINEERING _ -'7//~' ,,..7 4 g - ' o ~e ~,/ /?-/cF / 17034 Eagle River L~p Road N . /_. /., . C°mpai~'agle R~ver, AI=.~ 99~77 MOA No. ,-~/~;;;;'J"¢-'~ o .~ Date of Payment F ~/'~ ~'' 7 Amount: $ /¢ ¢ ¢ d Page 2 of 2 72-026 {11/84) in effect on the date of this inspection. o~o~oo~c~ ~,,¢o~c~:co~s o~ ~~, ~c. /~ FEDERAL TAX ID # 92-0040440 ~ MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENII?~J., HEALTH DEPAS(I~ENT OF HEALTH AND F/~]VIRONMENTAL PROI~ECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFIfP\TE 1. General Information Application Date / (a) Legal Description~ (includ~ lot, bloe~, ~j~bdivisi. on, .section, to~.anship, range) Location (address o~ directions) (~)ApplApplicants ::~icants es (c) Applicant is (check ore) Lending Institution L--~' Owner/builder~"~;~---~. (d) lending Institution !~/k¢;?//~_c¥_ /~_Z74//~¢l_ Telephone (e) ~al Estate ~o. & Agent Te le phone Multi-Family Other 3. Wate?z Suj?~l__~V Individual ~t~_.~ Community ~---~ ~blic ~ Note: If ~.mity ~11 system, must have .~itten confirmation frcm ~e State ~par~nt of ~viro~ntal Con~rvation attesting to tt~ legality ~nd status. Is the ~11 adequate for the n~,~r of ~Sr~ms spv~ified in this ~~'~ 4. O~sJ.t~ ~,b].ic [~'~ ~nnity E~ Holding Ta~k LUI Is the wastewater dis~sal s~stem adequate for ~e nt~r of ~dr~m [Page 1 of 2] 2-15-84 5. E_'n_ i~.~eri~. Firm Providinq_~_In_sj2~.,ctionsL .Tests, [k~ta and Information I certify thaJ~.I'~h~ave cbecked,/Verified, or conformed to all MOA. £tAA C~idalirms in Signed by Date (ENGINEER SEAL) 6. DHEP .Aj~proval Approved for c... bedrooms Appr OV~ d.~'~. Disappr. oved ~ Terms of Conditional App.'oval The Municipality of Anchorage Departra~nt of Health and Environmental Protection dces not guarantee the continued satisfactory perfomaanee (~ the, water supply amd/or the wastewater dispi~sal system. This approval indicates that, as of the validation date shown above, based on the data and information furnished by an engineer registered in t~ State of Alaska, the water supply hnd wastewater disposal system is .safe and func- tional for the numbe~ of be, dr~ and.type of structure indicated. (DHEP SEAL) 7. Mzail the HAA to, tb~lowing address: KB2/d5/s [Page 2 of 2] 2-15-84 5. )~ngir~,ering Firm l~oviding Insl~ec, tion_s_, Tests, L~ta and Infoc~tion I (~tify tha~haue ~cked, verified~ or conformed to all ~)A ~ C~ldgli~s in (mGINEER SF~) ~/~ f~ ~'(~:' ~, ~'' , ,' 6 Tern~ o.C°nditi°~al' , Ap~o. a~s. ~q~' ,~ ~~~A ~ ~k' ' k ' % ~__ ~.,~ '~ ~~.. (~~~~:~b" .... ," /1 '_ ........ ~e Municipality Of ~a~ ~p~nt of ~lt~and Envi~c~ntal Protection d~s not guarantee t~ ~inued satisfactory ~o~ne9 cf the wate~ supply a~/cr t~ was~wate~ dis~sal~ystem. ~is approval ~ica~s that, as of t~ ~lidaticn d~te sh~ ~3, k~d on t~/~ta and info~on f~nishe(l ~ ~ e~3i~er registGred i: the State of ALaska, the ~t~r supply ~d wastewate~ dis~al system is safe and furl, tional fo~ the number of ~ ~d ty[~ of structure i~dicated. 7. Mail (DHEP SEA[,) the, f~%lc~;ing address; KH2/dS/s [Page 2 of 2] KlM MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY OF ANCI"IORAGI~ DEPT. OF HEALTH & ENVIRONMENTAL. PROTECTION MAR 9 c ,- DATA .---- RECEIVED, Well Classification .-<~"~f-- If A, B, or C, D.EoC. ApProved(Y/N) ~A Well Log P~esent (Y/N: Date CC~leted . -~ ' I ' / ' Total ~pt~ ~ ~ Card to ~ / ~gt~ -- _...T. - Static Water ~Z~df/~¢7 ~) ~t At Casing Height Above Ground Elect/?ical Wi~ing in Conduit /~ Separation Distances f~cm Well: Sanitary Seal on Casing (Y/N) Depression A~ound Wellhead~(~-- To Septic/Holding Tank on Lot /O~) 7~ , C~ Adjoini~g Lots To Nearest Edge of ~so~ption Field on ~t //~ ; C~ Adjoining ~ts To Newest ~blic ~ Line 13 ~ To ~est ~blic Clean~t/Ma~oie ~ /~ --- To ~e~t ~ ~vi~ Li~ on ~t Wate~ S~le Colle~By ~'(~~ ~; ~te ~-- ~--~ ~ Wate~ S~le Test ~sults C~m'ents / SEPTIC/HOLDING TANK DATA Date Instal 1~ . ,.~O~/~_ Size /O~3~(p ' No. of Cc~artments ~ Standpipes:Y~) ~Air-tight Caps ~Y~N) Foundation Cleanout ~ Depression over Tank ~)'~ Date Last ~mped Pumping/Maintenance ~n~ct on File (Y/N~/~- .; fo~ __ ~////~ , -- Holding Tank High-Wate~ Alarm (Y/N) J///~ Temporary Holding Tank Permit (Y/N) Separation Distances f~cm Sep__~ic/Holding To Water-Supply Well /(J · To Property Line ~ To Water Main/service Lir~ /~//~ Course Tank: To Building Foundation 6 ~ To Disposal Field~_~-' ToSt~eam, Pond, Laker c~ Majo~ Drainage Consents [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field ~ Type of System Design~ / Length of Field ~.~ Depth of Field ~ f ~ Square Feet of Absorption~ea Depression over Field (Y~_y Results of Last Adequacy Test /~/ Separation Distance f~om Absorption Field: To P~operty Line To Building Foundation ~.~ To Existin~ or AbapT~ystem cn Lot ~//V~ ; On.A.d~oining LOts To Stream/Pond/Lake/c~ Majo~ D~ainage Course To D~iveway, Pa~king Area, o~ Vehicle Sto~age Area Con, rents D. LIFT STATION Date Installed Size in Gallons /~ "P~ 0~" Level at _~/~ ~ Tested for Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Electrical Codes (Y/N) Co~ts Meets MOA ** Check Permitted Bed~ocra Rating AGainst HAA Request I certify that I have checked, verified, o~ confc~u~d to all MOA HAA C~'i~s~in effect on tke date of this inspect m. [Ra~ 2 of 2] 2-15-84