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HomeMy WebLinkAboutHOMESTEAD HILLS #1 BLK 1 TR BHorn ad Hills Block T act B #015-173-22  MUNICIPALITY OF AI~CHORAGE · DEPARTMENT OF HEALTH & ENVIRONMEI~TAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ':' ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME IPHONE MAILING ADDRESS LEGAL DESCRIPTION .o. / . ~ DISTANCE TO: /00 ~ar~ 16 ~ Dwelling PERMIT NO. ~N ~ Manufacturer ~ ~6"¢ Material~~ No. of compa~ents i Liq: capacity in gallons Inside length Width Liquid depth lO00 ~ IF HOMEMADE: ~ ~ DISTANt: Well ~ling / PERMIT/NO.~ O z ~ Manu f~er = ' N / / ~te%ial ./ ~uid capacity in gallons ~,,~ DISTANCE TO: Well /~~'~ ,oundat,on ¢~/ NearestTrench~ Io~i~ PERMIT NO.~/~ ~ No. of lines ~ ~ ;..ches Length o~e~ Total ,en~t~o~¢ width ~ Distance between lines Top of tile to finish grade [/ ' Material ben.th'tile ~ ~ Total effective absorption are~ ~ Length Width ~ Depth PERMIT NO, ~ Typeofcr~ Cribdiame~ Cribdepth ~ Total effective ab~r~ ~ ~NCE TO: Well / Building~ndation Nearest lot ~ Class Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: B.iJdi~gfo.ndatio. Sewerli~e Septictank /~¢~ Absorptionarea(s) OTHER PIPE MATERIALS /~ REMARKS ~ ~ ~ APPROVED DATE LEGAL PERMIT NO. APPLICANT ROBERT MILBY BOM ~ll4 PALMER L. OCAT!ON T~PL~- b~. ~m~- LEGAL TRACT 8 BLOCK i HOMESTEAD HILL LOT SIZE DEF'RRTMENT '~-~, HEALTH RND EN',/I F.:ONMENTRL,,-'~"~OTECT I ON 82.5 "~ STF,:EET., ANCHO. O. RAGE., RK. 264-4,' 20 55000 SQUARE FEET TYPE OF SOIL ABSORPTION 'SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS SOIL RATING (SQ F'T?BR)= 85 THE REQUIRED SIZE OF THE SOIL ADSORPTION SYSTEM IS: [:,EF"-FH= ::t_2 I_E~-~uSTI,,I= .:~] GF:H"'.~EL [:~EF'TH== 8 'THE LENGTH DIMENSION IS. THE LENGTH <IN FEET) OF THE TRENCH OR 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). PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTRLLRTION INSPECTIONS OF ANY WELLS RDJACENT TO TFIIS PROPERTY RND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. BRCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION RND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL RND ANY ON-SITE SEWRGE DISPOSAL SYSTEM IS ~00 FEET FOR A PRIVATE WELL OR t50 TO 200 FEET FROM A PUBLIC HELL DEPENDING UPON THE TYPE OF PUBLIC NELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVRTE SEWER LINE IS 25 FEET AND TO R COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DAYS OF THE NELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. I CERTIFY THRT t: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET FORTH BY THE MUNICIPFtLITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLU[:,E MORE THR~ 2: BEDROOMS. SZGNED:-RPPLZCRNT R'"BFRT MIE~--~' -- ",- y ~ V4, 0 I ~:,UED B ............ [.,~TE ..... PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 ~ 4- 5- 6 \ 7' 8 9 10 11 ~12 14 15 16 17 18 19 20- COMMENTS PERFORMED BY: ,,~UNiCIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-E50, Anchorcge, Alaska 99502 276-222~ SOILS LOG- PERCOLATION TEST SOILS LOG .PERCOLATION TEST SLOPE DATEPERFORMEO; xl x' y PLAN WAS GROUNDWATER ~.~(~ ENCOUNTERED? Li o; P Ei IF YES, AT WHAT DEPTH7 : I D'~t° Gross Net Depth to Net Reading Time Time Water Orop I (minutes/inch) .MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TAT two 6!!90 Amba Atrl• 90111111 276'!!21 Ir SOILS LOG - PERCOLATION TEST 4 S YV .C/ /EltFoaMIED f01��9 d 8 1 1 L.� Y DATE PMPORMEOt /3 0 v91 B LEMI DESCRIRION going &D 1 LLS L dT / 0 DEPT// SLOPE SITE PLAN R " 1 (PERT) A Z 3 4 � s a ( 7 i a a� 1 4 t 'it, -"O Y ' Fi G 12 - 13 14- 4t6 Is - 17 17 (.�W to w 1st 20 n4 T, ��'• +b• .... 's WA GROUNO WATER Nc `l ENCOUNTERED? O IF VES, AT WHAT E DEPTH? ! PERCOLATION RATE This well is producing/":,'~(Oallonsf'~vater per hour. MOON DRILLING SR BOX 668,'BOGARD RD. PALMER, ALASKA 99645 TELEPHONE '~,45-4071 WELL LOG Set pump /"~--, feet. INVOICE NO._ DATE /' ' ' yOUR P, O* NUMBER __ TERMS - ~ '/ SALESMAN , t DEPTH ( ~ CA$IN FORMATION DEPTH /// )EPTH ~f'~CASIN FORMATION IN FT. N FT. ~, CASIN FORMATION IN FT. ~ -- ~ 201 s i I los -----T -2os-- ~S_ ~ I 106 t I '206-- ~ "214 I '-'-~r~ ~15- { '116 ~ f ' , , , , ,"/'_ __Sl ) L2! I t ,'/i ,; ''~ / __22 ~ ~ 128-- f ~ --224 ~s , t 124 i .. , 2s ~ I ~26 ~ ~ 227 30 i I 131 t ~ , ~S1 ~ ~ ~ ~ · ~ :~' 232 23 J ~ '? / ~ ''~ { 133 I ~ ~ ~234 __84 ~ l /~l fI.t~ ~ --134 ~235~I 139 ! } /' ~ ' 240 --SS ~ ! ~ 140 ~ ~ ~' '~" ' ~40 I ~ 141 { ~ :'' "242 ~47 I i 147 i ! 248 -- z~1 ~ ~ 2s2 .... ~"'?0 ~ I 170 ! ~ 270 --272 I ~74 i ! 174 ) ) 274 176 ; ! "276 287 - "'187 ~$7 i ~ 285_.~ 92 f /' 293 --97 : '198-- ; '---- i 298 '- -- 99 ~ 199 { --- ) ,.~ · , ~ .-,~,.., ,' g.,. ) ? ::/ .,: AMOUNT PLEASE PAY FROM THIS INVOICE ~ / Parcel I.D. # MUNICIP,~LI3¥ OF'ANCI~IoRAGE': ' DEPARTMENT OF H~TH & HU~ SERVICES O~ite S~s ~ CERTIFICATE OF H~TH AUTHORI~ ' APPROVAL FOR A SINGLE F~LLYDWELLING" 1. GENERAL INFORMATION Complete legal description HOMKSTFAD I':ltttS SUBDFAS~;::)N: T _I~T' B"~ 'Z¢-~/'-I~'. I Location (site address or directionsi' 4~25 TRAPLINE' DRIv~: A~dHORA{;F AK' '99516 ' Property owner SAUNDP, A KNOX Day phone . - Mailing address 4225 TRAPLINE DRIVE. ANCHORAOE AK 99516 ' ' Lending agency. - .... ' Day phone · Mailing address : Agent Address ~s25 "c" STREW. ANCHORAGE AK 99503 Unless othen~ise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: CONNIE HARRIS w/ COLDWFLL BANKER Dayphone (907) 227-0921 If community well system, provide wri~en confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTE~NATER DISPOSAL: Individual on-site xxx Holding Tank Community on-site Public sewer NOTE: If community wastewater system, provide wdtten confirmation from State ADEC lng to the legality and status of system. 724325 (Rev. 1/91) Front MOAff21 Computer Version Note: A/aska. Water. and Wastewater Consultants, In.c.. s. ha/I be paid $700.00 at, or prior to, closing for the engineering services pro~eeo. 5. STATEMENT OF INSPECTION BY ENGINEER As Certitied by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation of this Health Authority Approval appllcation 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 tiles and from my Investigation and Ir)§pection, the on-site water supply and/or wastewater disposal system Is In compliance with all Munl,.ci~tl and State codes, ordinances, and regulations In effect on the date .of this Insp .~on.. . /'~ ! I Name'ofF, rm- ALASKAy~-'TFR~& ~/A~"I~TERCONSULTANTS, INC. Phone {907)337-61~9 Address 6901 D~B^RR/'ROA[.~ r~ 2~ANICHORAGE. ALASKA 99504 Engineer's signature ~k.._...~/J ~/~'--J. ' Date Inconduct/ngthisevaluat/On, AWWC,~+.~tt~ ~ptedtopro~deathorough, consclentiousengineedngana~slsoftho system In accordance with ADEC and f~OA D, -IS Guidelines & Regulations. The reported results described the pedormance of the system under the condition~ encountered at the time of the test, and separation distances measured to readi~y identifiable features. The operational life of all wells and septic systems depend on the local soils condition, ground water levels that may fluctuate durfng the year, and the water usage of the family being served by the system. These conditions are eutside the conYol of the evaluator of the system. Satisfactoo/ test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC,, Inc. can therefore not provfde any warranty for futura est/mate of how long the system will continue to meet the oporational requirements of the ADEC or MOA DHHS. The content of this report Is for the sole benefit of the owner listed abev~. Any reliance upon or use of this report by any other person or party is not au~odzed, nor will it confer any legal right whatsoever. 6. DHHS SIGNATURE ~ Approved for ~ Disapproved Conditional approval for bedrooms bedrooms, with the following stipulations: Additional Comments .. ~ · ~IERAND · ~. Date The Municipality ef Anchorage Department ef Health and Human Servlces (DHHS) Issues Health Authority Approval Certiticates based only upon the representations given In paragraph 5 above by an Independent professional engineer registered In the State ef 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 ls not responsible for errors er omlsslons In the professional engineer's 72.025 (Rev. 1~91) Back MOA#21 Computer Version Legal Descrlpfion: A. WELL DATA Well Type PRIVAT~ Leg present (Y/N) Total depth 226' Sanitary seal (Y/N) Municipality of Anchorage .DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 "L" Street, Rm 502 Anchorage, Alaska 99501 (907) 343.4744 Health Authority Approval Checklist HOMESTEAD HILLS SUBDIVISION; TRACT B Parcel I.D.: If A, B, or C, attach ADEC letter. ADEC water system number YES Date completed Cased to 225' 015-173-22 Date of test Static water level UNKNOWN Well production 25 WATER SAMPLE RESULTS: Coliform 0 Data of ~ample: 3/20/01 B. SEPTIC/HOLDING TANK DATA Date installed 7/2~/8~ Tank size Foundation c~eanout (Y/N) YES · Date of Pumping 1/23/2001 C. ABSORPTION FIELD DATA Date installed 7/23/8 ~ Length 17' Width EtfectNe absorption area 272 SQ FT Date of adequacy test 1/23/2001 Fluid depth in absorpUon field before test (In.); Ruid depth 65"/58" (ins) Minutes later. Peroxide treatment (past 12 monl~s) (Y/N) FROM WELL LOG 4/12/8 ~ N/A 4/12/81 Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION 1/23/2001 170' g.p.m. 6.1 g.p.m. 30" YES Nitrate 0.936 mq/L · Other bacteria 0 Collected by: A.W.W.C., IN(:;. 1000 Depression (Y/N) NO Pumper A+ HOME S~:I~VICES Soil rating (g.p.d./ff2 or ft2/b~b:m) 85 UNKNOWN Gravel thickness below pipe Number of Compartments 2 Cleanouta (Y/N) YES High water alarm (Y/N) N/A *3" ABOVE INVERT OF I OISTRIBUTION LINE *'S,,UMP~ ONLY EXTENDSI 188 ~E:ow ~NVERT. I S~tam type TRENCH 8' Total depth ~ 2.8' Monitoring Tube present (Y/N) '*YES Depression over field (Y/N) NO Results (Pass/Fall) PASS For 3 Bedrooms 54" Immediately after 509 gal. water added (in.): *91" 238/1331 ,Absorption rata = 450+ NONI~ KNOWN If yes, give date O. UFT STATION Date installed Manhole/Access (Y/N) ~yoles~sted *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 100'+ 100'+ N/A 25'+ On adjacent lots 100'4- On adjacent lots 100% Public sewer manhole/cleanout N/^ L~ station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'+ Property line 5' + Water main/sen/ice line 10'+ Surface wetarldrainage 100% SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: 10'+ Building foundation 100'+ NONE KNOWN Absorption field 5'+ Wells on adjacent lots 100'4- Property line Surface wetar Curtain drain 10'4- Water main/service line. 10'+ Driveway, parking/vehicle storage area 10'+ Wells on adjacent lots 100'+ F. ENGINEER'S CERTIFICATIOI& of Municipal rqbord~ ~/t/,hd~b } s~mms em in ~n~an~ ~ MOA ~ g~s ~ on ~/s date. Signa~m~ ~ ~ Engln.~ N~7 ~ CARNESS Da~ ~ HAA Fee $ ~ .~0 Date of Payment ,:~/o~/(~)/ Receipt Number ~ Iq ~, 72-026 (Rev. 3/96)' C.,~mputer Version Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL ~ALTH ~" DEPARTMEN~ OF h~ALTH AND ENVIRONMENTAL PROTECTION A~PLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date ~-~ ~ ~ ~ .~ (a) Legal Description (include lot, block, subdivision, sec~tion, township, range) Location (address or directions) (b) Applicants Name lY~m,~ D~-c: 4~ :~ ~. Telephone - ~ome Business 5'ZZ -/03 C) Applicants Address ~A Mo~ 133G - 2 ~cha~.~ ~%m q9~-;~_ (c) Applicant~Is (check o.~ne) Lending Institution ~--~ ; 0wner/3~~.,; Buyer ~--~ ; Other ~ (explain); (d) Lending Institution A///~ Telephone Address (e) Real Estate Co. & Agent_~ Address Telephone (f) Mail the HAA to the following address: e Type of Residence Single-Family.~ Number of Bedrooms Multi-Family~--~ Other (describe) Water Su~- Note: If community well system, must have written confirmation from the State Department of Environmental. Conservation a~testing to the legality and status. Sewase Disposal.. 0nsite ~ 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] e e Engineering Firm Providing Inspections~ Tests~ Pile 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 regula- tions in effect on the date of this inspection. Name of Firm ~C5 Telephone ~/-5-(5 ~ Address. p~EP Approval Approved for ~-~ bedrooms Approvedx Disapproved __ Terms of Conditional Approval Conditional CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF REALTH AND ENVIRONMENTAl. PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. TI~E MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OK OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 DEPT. OF HEALTH & '~'~IRONMENTAL PROTECTION, A. WELL DATA R E C E I V E D CHECKLIST - FEBRUARY i984 Well Classification Well Log P~esent ~.~/N) Total Depth '/~'~2~6~J~ ..... Cased to Casing Height Abo~ Ground PJ'lect~ical wiring in CDnduit ~XN) separation Distances from Well: , De~th of srouting/I!~ ~ Sanitary Seal on Casing ~ZN) Depression A~ound Wellhead (Y~ To Septic/Holding Tank on Lot i,O<~ ~ TO Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ~//~J~ To Nearest Public Sewer Cleancut/Manhole ~/~ To Nearest Sewe~ Service Line. on LOt Water Sample Collected By -~,~I.~.~-.Y~'' .; Date Water S~ple Test Results c~nts ~ ~ ~i~ ~/~/~ / ; O~ A~joining Lots / , / 27~>~-',; On Adjoining Lots B. SEPTIC/HOLDING TANK [I~TA Date Installed 7~/~3/~/ Size I0~'3~_~)%3cc~ / NO. of C~a~tments Standpipes ~F~N) Air-tight Caps ~/N) Foundation Cleanout ~/N) Depression ove~ Tank (Y_~3~ Date Last Pumped Pun~ping/Maintenance Contract on File (Y/N) ~//~, for /~//~ Holding Tank High-Wate~ Alarm (Y/N) ~//,/~.. '%%mporary Holding Tank Permit (y/N) ~/~ Separation Distances f~om Septic/Holding Tank: To Water-Supply Well I~.~L To P~oper'ty Line 'i/7~- / dp T© Wa~r Main/Service Line '~/ /~ TO Building Foundation /~ / O TO Disposal Field ?./~-~~ TO' Stream, Pond~ Lake, c~ Major Drainage COmnents ~ , [Page 1 of 2] 2-15-84 Ce Soils Rating in Absorption Starata Date Installed ~ / ~3/~ i / System sign. ~ngth of Field l =/. ~I- ~' Width of Field Square Feet of Absorption A~ea Depression over Field (Y~ Results of Last A~lequacy Test Separation Distance f~c~a Absc~ption Field: To ~te~-Suppiy ~ii / ?.* To Building Foun~tion Lot ~//~ ; To ~te~ ,ain/~vi~ Line To St~e~ond~ke/~ ~jo~ ~ai~ To ~i~way, Pa~king ~ea, ~ Vehicle St~a~ ~ea D. LIFT STATION Date Ins~ Dimensions ~._---- Size in Gallons~_ Manhole/~/N) ' "Pump On" Level at ~f" Level at. _ High Water Alarm Ievel at J ~ (Y/N) Tested for ~ing Cycles dutring ~Meets MOA Electrical C~ments ** Check Permitted Bedroom Rating AGainst HAA Request ** I certify that I have checked, verified, o~ conf(mrmed to all MOA HAA Guidelines in effect on the date of this inspection. Signed ~J ~, ~/~4~/~ Date Company //~ MOA No. KB1/d5/s [Page 2 of '2] 2-15-84 ALASKA I FIUIROFImI FIT^L £OFITROL $1 RLIICe$, ifil::. ~nclincerincI ~ ~nuironmcniol Sluclies JULY 19 1984 MARY BEAUSCHM AN SRA BOX 1736 - I ANCHORAGE AK 99516 SELLER - MARY BEAUSCHMAN BUYER - KNOX SUBD~ON - HOMESTEAD BLOCK - LOT - TRACT B ADEQUACY TEST FOR SEWER SYSTEM THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 272 SQFT. THE SYSTEM T~ CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 500 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 3 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON 7/19/84 . FLOW TEST ON WELL THE WELL FLOW RATE WAS 3.13 GPM FOR 2.66 HOURS. SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1000 ]~ ADEQUATE FOR TH~S 3 BEDROOM HOUSE. .... Ill ...... J D, ....... t.,;,~ R. A..L ..... AI,M.,~ qq~n-~ergo71 561-5o40 mDATE'RE~EiVED " ; INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR I NSPECTOF~ (~L~.~ MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. OF :~,.d.l~l &  DEPARTMENT OF HEALTH & ENVIRONMENT~~ P,~O~CTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISIO~ Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE ILITIES DIRECTIONS: Complete al~ parts on page ~. Incomplete requests will not b~ processed. Please allo~ ten (J0) days for processing. 1. PROPERTYOWNE~ [ PHONE MAILING ADDRESS PROPERTY RESIDENT {If different from abo~e) PHONE PHON~ 2. BUYER 3. LENDING INSTITUTION I PHONE MAILING ADDRESS 4. REALTOR/AGENT I PHONE I ~AILIN~ ADDRESS 5. ,EG , DESC"'PT'Oy / STREET LOCATION 6. TYPE OF RESIDENCE  S INGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY INDIVIDUAL* COMMUNITY [] PUBLIC UTILITY NUMBER OF~BEDROOMS [] One [] Four [] Other~ [] Two [] Five ~' Three [] Six * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM E~/ INDIVIDUAL/ON-SITE** 4,/ [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev, 6/79) ~ THIS SIDE FOR-OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEI~ROOMS [] ONE [] THREE [] FIVE [] OTHER [] SINGLE FAMILY ,' , [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY, [] INDIVI DUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY ~'~' Connection Verified INSTALLER r-]Septic Tank or []Holding Tank Size: J~)~)~) If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER~L~, .~' TOTAL ABSORPTION AREA MATERIAL ,.-~~ 4. DISTANCESwELL TO: Septic/Holding Tank IAbsorption Area ISewer Line ] Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS [~;~'~PPROVED FOR ."~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY