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HomeMy WebLinkAboutNETTLETON ACRES #2 LT 1  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 , ]PHONE ~NEw " ~AILINGAD RESS ~ - LEGAL D ESCR~ LOCATION// ' N~. OF BEDROOMS Well Absorption area Dwelling DISTANCE TO: ~ ~ z PERMITNO. ~ ~ Manufactuf~,~ ~ O ~ Mpt~a~ ~ ~- No. ~°f compartments Liq. c~pa~hy in gallons Inside lengtl%~ Width LiquM depth /~ O IF HOMEMADE: ~-- , Foundatio~ Nearest lot line ¢ PERMIT NO. ~_ No. of ],nes~ '~ ~. Length of eac~ Total length o~,nes~_~[~ ~Trench~'/2.o'~width inches Distance ~tv7 ~, ines ~ Top of tile to finish grade L/. ' Material beneath tile ~.~- Totaleffecti~eabsorg~narea Length Width Depth PERMIT NO. ~m ~- ~ Typ~ffcrib / / ./Crib'~aFnet~r/ / ~o th ~/. ~TGtal effec e absorption ........... area ~_~_.~ - ~/ DISTA~E'~ Well~/ Building~ation Nearest lot lir~ ..... ~' ~ s~ Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS ~ SOIL TEST RATING __ ~ INSTALLER ~ I )fl f ,,- ~.o ~PPROVED ~D ~ATE LEGAL 72-013 (Rev~..3~]'~8~ [:,EPRRTMEN'f' .-' HERLTH RND EN',,,'IRONMENTFIL . ROTECTION :.:.:;E:5 '"L'" STREET., RNE:HORRGE., RI-.'.':. 2,~4-4 7;;.::0 PERMIT NO. ,' 8'1.}J.~'::' ) RPF'L.! ]F~NT HRRR'¢ R. f,IRFKE'¢_ . STRR R(]UTE ~ ....... P"..,' 2.~.'75 ':~':~;:' F%''"'=.=.:,-,~>=d.=,.'-''''''' =' I...OI]:FtT I ON HI31'"I~.STE~"RE:E:CFI'T RI]FIE:, LEGFIL L J.~.~74ETTI_ETON RCRE% tf;~ LOT 2;IZE ~Z E08E~ SI%¢JRRE; FEET t~FE. OF SOIL. HE,~,URF FION :,~_,lEII IS' TRENCH tll-h..,:[MIJH NI..i','IP, ER_ OF E,E[E.LLH= = 4 SI]IL. RRTII'.,tG THE F.'E'.:~JIF.':ED SIZE OF THE .c..;OIL FIBSEIF.:F'TION E;'-r'STEH IS: THE LENGTH DIMENSIOI'.,t IE; I'HE LENGTH (IN FEET) OF ]"FIE TRENCH CIR DRRINFIEL..B,. THE DEPTH OF' R TRENC'H OR PIT IS THE B, ISTFtNCE BETI.,.IEEN THE SUF;'.FF~CE OF:' THE I]ROUNE:, RN[:, THE Br.)TI'OM OF THE: EXCAVATION ,.'.'IN FEET]:,. THERE IL=.; NO SE"[' P.I;r.E:,TH FrOR TREI'.~E:HEL=;. THE EiRR'v'EL DEF'TH IL:'; "I'HE HI'I'.I:EHI..IM DEPTH OF' GRRVEL BETI.4EEN THE OUTFRLL. PIPE FIND THE E:O'I'TOH I]F 'THE E;:',:CRVRTION ,:.'Ii'.,I FEET). PERH I T F F'F L I .:FII',IT FIFIS THE F.:E:SF' :d'.,l='5, '[ E: I L I T'T' TO I NI:I]RH TH 12; [:,EPFIRTMENT [:,I JR I i"J. Ei THE II",ISTRL LFITION. IN=;FE::TIOI'.,IS OF FIN'¥' !.,.IELLS Rr.:,..'rRCENT TO THI'=_, F"F. JF .... EF.,'"I' ~ FIND THE NUHBER OF F,:E=,IE. EH.E=, THFIT THE I.,.IELL !.,.IILL. '.E;ER;,,'E. ....... ql"' II.....~ C,, ,:" ;.:2' ":,I ~'-.1t .=:. !t- E. ,._. T ,I C, ~'-.! ,'~]; .... "' .... .... HI ....F... E. IF.: EE ~l]:~ E_It % t~'.' IE): E]:, E~FICKF I L..L I NEi OF FIN'¥' S"r'STEM ,W I THOUT I= I I",IRL.. I N':~,F'ECT I ON FIN[:, RF'PR ] ',,"FIL E?'r' TH I 5; r.:,EPRRTMENT NILL. BE "' " :, .IE,..) E... T TO F'ROSECUT I HII'.,IIMUH [:,IT'=Tf'FINC:E BETI4EEN R NELL FIND RN'T' ON--'SITE SE,klFIGE: [:,IE;PO'.::';RL S'T'$TEM I'_:; ::L00 FEET FOR Ft PRI',/FFFE NELt. OR :1.5F.~ TO 200 FEET FROM FI F'UBLIC IqELL [:,EPENDING LIF'CIN THE T"r'F'E OF F'IJBLIC NELL HINIMUH [:'ISTFINCE FROH R PF.:IVFtTE NELL TO Ft PF::I'v'FFFE SFI4ER LINE IS ;?.5 FEE]" F~I",I[:' TO R COHHUNIT'¢ SEI.,.IER L. INE IS 75 FEET. 14ELL LOGS RRE RE~2UIRE[:' FIN]:' HI..IST BE; RETIJRNE[:' TO THE [:'EPFIRTHEI",IT I.,.IITHIN r.)F THE !4ELL COHF'L. ETION. OTHEF.': RE6!LIIREMENTS HR"r' RPPL."r'. SPECIFICRTIONS Rt',l[:' CONS't"RLICTION DIFIGRRH'./.'; RRE F:IVFIILFIE:I...E TO INSURE PROPER INSTRLLFITION. I C:ERT I F"r' 'I'HFIT :.l.: I FIM FFIMILIFIF.: NITH ']'FIE I;..'E~]UIF,'EHENTS FOR OI",I-SITE SENEF.:S RNF;, I.,.IEL. L..S FI~5 'SET FORTFI B'T' THE HUN II::IF:'FILIT'¢ OF FII"4CHORFll.'3E. 2: I 1.4ILL INSTI::II._L. THE :5'¢~;'T'EH IN FICCOF.':bFII",ICE I.'JITH TFIE COB, ES. l".;:: I L.INE:,ERSTFINr.) 'f'HRT THE CIN-~=.;ITE SE!-,.IER S'T'STEH HFI"r' REIZ.!UIRE ENLFIRGE]"IENT IF: THE I~'.E:E;I[:,ENCE 1:5 F.:EI"IEIDEL.E[::, TO I NCL. UDE HORE THRN 4. E',EB, ROOHS. SIGNE[:,' ...................................................................................... ~ / ¢0-1 FIPF'I....ICFINT HFIRRY FI. FIFII::KE'.r' ,/)t ¢l("t ~' /(¢¢D 0 L~I / MUNICIPALITY OF ANCHORAGE Department ~ Health and Environmenta_ ?rotection 825 L Street, Anchorage, AK. 99501 264-4720 * * * HANDWRITTEN PERMIT * * * WELL AND/OR ON-SITE SEWER PERMIT Applicant: ~t~[C'f~ ~Q~C~_~.W Mailing Address: ~, ~.~. Location: ~)Y~3~¢L~ ~ ~(~-~ Phone Number: _ ~ $~ - ~ A~ Legal Description: .L[~'~ ~(~'~6~ ~Cr~%'f~.~_ Lot Size: [. Type of Soil Absorptio~n S~stem Is: Trench: Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: ~-- Soil Rating (sq. ft/br) The Required Size of the Soil Absorption System Is: DEPTH tO LENGTH ~ _ GRAVEL DEPTH ~ WIDTH 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 PJ. pe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) 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 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 1 * * * 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 Signed: ~esidenc~r~o~led to include more that ~_edrooms. Issued by: .oJ~ -c~- Applicant ' ' Date: SWP/024(1/81) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG-- PERCOLATION TEST /~/ SOILS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: I 2 3 5 7 12 14 17 18 2O ~AR, R¥ ~'~ SLOPE SITE PLAN WAS GROUND WATER ~1 ENCOUNTERED?:. D [ 0 P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop ~, PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN ~ FT AND FT _ '7',.~,d, ~*~'[v '~ 6 ( 1~/~ ~,~- /~.~L. PERFORMED BY: ""'~ ~'~ OERTIFIIEDBY: ~'¢ ~~ DATE: 72-008 (6/79) 72-02~ (Rev. 1/91) Front MOA~I As ce~fled by-my seal affixed hereto ~nd as ofthe validation date shown below, I ven~ thatmy '- ~: i~v~tig~ti~`~:~is~ Hea~A~h~r~ ~pp~v~`~cati~n~sh~ w~:.t~a~:~e`~site~ wa~e~p~y ':~'..} and/or wastewat~r disposal.system is-~af~,'fun~'io~ai and adeq~ate forthe ~mbe~ 0f b~oo'ms ' and ~pe of,st.[U~t~re indicated herein. I fuAher veri~that based on the information~ obtained from the Uunicipali~ of Ancho~age files and from my inv~s~ati0n and insPection, th~'on-site ~at~r supply and/or wastewater:disP'~'~l' System'is in corn pllance with all Municipal and S~ate codes, ordinances, and r~ulAtidns'in eff~0n the date of this inspection: :' - .'--- · ' · ':~">':. ........ :. ~-": . .: .... ~ ....'.'.':;_X::.'. '.,..-."- :.: :::: :.'.:~._ ~A[SProval, r )on::~the'mpresentations given in:ParagraPh 5:above'byan~.in~lepend,ent ,. ':--~ p[{3fessm ,= ster~ n the State of Alaska. The DHHS d~s th~s as a cou~esy to purchasem of homes. :; ::'::.an~l I~ ~ns~r orderto~t~ce~amfedemland~ter~u~remen~Employ~sof.DH~Sdonot ' ar ' ~ ;.;-c,~n~uct.~ ) .g,r~a~l' ~ dat~ before a ce~l ic~te ~s ~u~.:~he ~un cipa ~ of:?Q?orage' is not >:: :- ,. :, responslb or en om r om, I in the profe~i mai engln.fs Wo~.:; ::::: ,,:.::;:z: <:: ~'~,.::.r ::??::::~;:::. :,, , 72-025(Re¥,1/91) Bac~ MOA~I Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. Well Data Well type ~IO~T~-- Log present (Y/N) Total depth Sanitary seal (~/N) If A, B, or C, attach ADEC letter. ADEC water system number ~-5 Date completed ~'/,~-~( Driller ,/~/7'~..// -~,~ ' Casing height Wires properly protected (Y/N) Cased to FROM WELL LOG Date of test ~- 15'~ I Static water level ~ ~ Well flow I 0 Pump level1 '~O .~ SEPARATION DISTANCES FROM WELL TO: Septic/hetdh~ tank on lot Absorption field on lot Public sewer main Sewer service line /Q g.p.m. ATINSPECTION g.p.m.tr,-~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ,~ Nitrate Date of sample: ~-~-~ B. SEPTIC/HOEBtN(i TANK DATA Date installed ~;/oR/ Cleanouts ((C/N) ~5 High water alarm~ Collected by: Date of pumping Tank size Foundation cieanout Other bacteria /,~ .,~ :;. g ,',~NGINEERING Compartments ~ Depression (Y/~ ~ ~ Alarm tested (Y/~ ~ SEPARATION DISTANCES FROM SEPTIC/H~LD~,N-G TANK TO: Well(s) on lot J 08 To property line Surface water/drainage On adjacent lots ! Oo t¢ Absorption field '::¢ ~ Foundation Water main/service line 72-026 (3~93)° Front CONTINUED ON BACK PAGE . TAT O Date i~ Manufacturer Size in gallons ~~ at ~ "Pump off" Level at Vent (Y/N) ~evel ~ High water alarm level ~ Cycles tested Meets MOA electrical codes (Y/N~'~'''''''~ ~ on lot On adjacent lots Suda-Ce-v~te.~....._ D. ABSORPTION FIELD DATA Date installed ~ [~ ~ Soil rating (GPD/FF) Width ~ / 0 ' Gravelthickness ~, © Cleanout present (~¢)N) ,,V~q Depression over field (Y/N) Length Total absorption area Date of adequacy test ~ / ~L/~-~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/I~ Results (pass/fail) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I C~ ~ ¢ On adjacent lots To building foundation [ ~ ~ 'f On adjacent lots ~ ~ ~ '~ Cutbank Sudace water F¢¢5% for ¢ Bedrooms Aftertest If yes, give date /00 -/ Property line To existing or abandoned system on lot /--2//} Water main/service line Curtain drain Qb 10 ' Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I cerb'fy that I have checked, verified, or conformed to all MOA and HAA Signature Engineer's Name Date CE-880! this inspection. HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number 03/13/95 12:15 COMMERCIAL TESTING * 90?6941211 Matrix Client Mample ID CT&E Environmental Services Inc. Laboratory Division ps.08 -i Laboratory Analysis Report WATER L1 N~TTL~TON ACRES ~2 ClSent Name S ~ $ ENGIneERInG WORK Order 13105 Ordered Fy R. SHAF~R Printed Date 03/13/~5 ~ 12;21 hr.. Project Name collsuted Da~e 03/08/~5 ~ 14:30 hrs. ProJe~ Received Date 03/08/95 ~ 1~:~0 hr.. Technical Director STMPHEN C- Sample Remarks, ROUTINE 8~/~PL~ COLLMCT~D ~Y: J.W. QC Allowable Ext. /~nal Parameber Re~ul~e Qual Units Method Limits Date Date Init Nitra~e-N 3.3~ D mg/b ~PA 3S3,2 10, 03/10/95 CMR See Sample Remarks Above ~A = Not Analyzed Undetected, ~ep~r~ed value ~e ~he practical qUan~if~catlot~ limit. LT - here Than Secondary dilution. GT - Greater Than 200 W. Power Orive, Anchorage, AK 95~I 8-1 605 -- l~l: (907) 5~-2343 Fax: (g07) 551-5301 ENVIRONMENTAL FACILITIES IN ALASKA, CAUFOflNIA, FLORIDA. ILLINOIS, MARYLAND, MICHIGAN. MISSOURI, NEW JEI~$EY, OHIO. WEST VIRGINIA ': '"~'-':~ .... i'. ..... ... [~...~1 .~t~-,... ~ DEPARTMENT ,OF HE,ALTH & HUMAN SERVICES "" '--':,~r~ '?f~;~'~ ~'~ ', ~ · ,.. ~', ' ., . ' · · · .- ., ' . ;' -' '. ~ ' DIws~on of Enwronmental Services' .,./~,:?,.'2~(¢o¢~b~.d-~,:, .'~%~,¢~(~-',, ~,~::2 P.O;'BoX ~196650 :Anch0¢Age~-Alas~a'~c~51 ......... -.. .... > ...... ..~ ....... . , CERTIFICATE OF HEALTH AUTMORITY ?;?.;:~'*:?,~. ?..;..;.: '--.:%-. ' -...;?-.' - ·APPROVAL FOR A SINGLE FAMILY DWELL NG . HX ~ ~ ~o~ ~x~ ':'- :' :?:"--' ' ....... ...... .: "~' ~ 't" : "' Complete legal description '~OZ '. ': ...... :"-'" ............. ' '- .... V', ........ ;" .... Location (site address or directions) · . Mailing address ¢/2-~o ~"/~'t f~ Lending agency ~ ~A C ~ &~ Day phone Address Unless otherwise requested, HAA will be held for pickup. 2, NUMBER OF BEDROOMS; ~ ,- 3. TYPE OF WATER SUPPLY: ':;~" ,' Community well' -.':- · Pubicwater · :.' ..,: . - NOTE: If community well system, provide written confir,,n~ation from State ADEC attest- . .. · ~ng.to the ~egau~yan~ status orsys~em. - _ ~%' ~ ~' ':-* <:,'.~( ::-- .~ ~ - i~'~ ~ '~-'k"' ": "".~.,~'~'".'.-' -' ''~'' '-' ,4. TYPE OFWASTEWATER DISPOSAL: ' ' . .... :.', . ' :' ~'- . ~-..~..,;~,,: .......... :.~: ,-:i~:~,';:1 ndividual on-sit~t ......... .~..~-. :.-.~:~,-~,?~;~..:.,.'~,,,., ,,; i.-- -.-.~ ~--,~,~,,,--~.:¢~,;~,,.~.. :..,.~,~, :~:,~; '-. ~-'-" ~ ' :' ' .~,%..: ,',:.¢ ::','.,,i 'n~; ~:.-Community on-site,.--.... ~,~ ..... _ .~:.; r~;'I] ~:*r-,., ',:',o r?'-:-- ~?:~,ti~.:h,,;.'~;;!~-, ~.-?.,.,~. . '.'NOTE:" ' If commumty wastewater System, provide written confirmation from State · ' attesting to the IogalitY'"~d'~ta"t~s'O'f 72-025 (Rev. 1/91) Front MOA #21 ' '. : ';' suo~e'ndls Bubo o~ e ~ q~ 's~ooJpeq , .' 'Jo~ leAo~dd~ ~¢~q~puoo4~ 't . ,::.,.:.~, ,:'::.~;:;::';..:..::- ..,~- ,.,.. : .: ~-,, ¢ p,:c,...b~-- · - euoqd - ~ ~ ~ ¢ ...... ze~ ez s uo euz 'uo oedsu puc uo 1~8 ~seAu ~ ~oJ~ pub se Ije o un~ q~.,. ..... ,; ...... ,, -is. _. - _. ~ ..... , . . .,,.,, . ~_,; .. .._.. . ). . . '~~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT ): NET-FI.C,'FOt, I ,NCf~A ~"~: Parcel I.D. O l~ .- oG 2..-- 04% A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) _ If A, B, or C, attach ADEC letter. ADEC water system number Date completed "~' ]~" ~ ! Driller Cased to -7 2_~ Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL I.OG AT INSPECTION .¢'/~" ,~1 ~. 2..~/.~/ I iD g.p.m. ~ 7o ~ ~o~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot _ Absorption field on lot Public sewer main Public sewer service line h"/'/'~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout. Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Date of sample: /';/" ~:~J' ~ / Collected by: Other bacteria B. SEPTIC/H,ll)LflEHN~CTANK DATA Date installed ~¢'3 J ~'1 Tank size Cleanouts (Y/N) ~ High water alarm (Y/N) Date of pumping 7' Compartments Depression (Y/N) Pt/ Foundation cleanout (Y/N) . Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot IlO Onadjacentlots "~ /0,-o To property line ~o ~ Absorption field 7' Surface water/drainage ~,'"//',4~ ~: ' : : Foundation Water main/service line 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length '~C:) Width Total absorption area --~ ~ Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) ~ Soil rating ~ ~ System type Gravel thickness ~ '~ Total depth /-~ Cleanouts present (Y/N) Date of adequacy test ~','//' for /~' bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / ~5 To building foundation On adjacent lots Surface water Curtain drain /"////-~- On adjacent lots ~ /~¢4:3 Property line To existing or abandoned system on lot Cutbank F¥'//,~, Water main/service line Driveway, parking/vehicle storage area /O 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. Engineer's Name Date HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 67,51 ~. DIIiDND L~LgI). ¢INCHOR6BE, ~ILASK¢~ 99502"3q0z] (907) 2~.8~5095 LEGAL: LOCATION: OWNER: RESIDFNCE: S:i.l'H::l].~.:i:, F;'~:wl:i. t ,:,.',, a WELL: SEPTIC SYSTEM: F:'I::~C)M MUN I C; I F::'(q_. F:~IiX'_'.ORDS ~ xl )'}:ecl I" c)(::)m ~];'¥'!i?[: (':ff3SOF;d'::'T]:01q SYSTE]"'I:: 'frc. nc:h AJ{~SORF::'T:I~ON AREA~ 360 Scl, F::'t ,, SC) II. RA"f']:NG: :[IqS'I'ALI, AT I E)IW ):)A]"I~ ~ May 1 9~]:[ DATE OF LAST F"t. JMPING: AI]C;J),, C (-:::, s '. i; F'c)c)l (.'q:::, r" :i. 1 3(),, ].9':2:1. DATE OF TEST: TEST PROCEDURE: ,%'/s't:~,:..)rn was :i. nst::)c, ct::~.::,d ar'rd 'l'r'fx~r'H:::h c:] (.:.:~?ll'i (:]Lt'~] ~,.'.~-i'~!~ ~,1 .~:(.!.:,(.:!y[.~ C](.:.?C,p ~.'~l'~t~ dl""'¥',, 'J"F'(.~I~I:::H lfiC)r'l:i. ANCHORAGE, ALASKA 99502-5904 (907) 248-50% LEGAL: LOCAT I ON: GWNER: TYF'E OF WELL: Joe ~_)~?wr'~.::,y Pr'i vatr~:, ,~ S:i, ngl I.;~ I:::'ami 1 y WEt_L LOG AVAILABLE: Yes I NSTAI_LAT I ON REQU I REMENTS MET: Y~::{,s WELL YIEI_D FROM ~ELL I..i]G: F'UI'"IF' YIELD FROM TEST: DATE: OF INSPECTION: TEST PROCEDURE: Wc.~ll ~,,.,a~:~; pumf::,ed a'!: a (::c)nst:arrl.: r'at<~(, ~,,..,li:i.:l.(:.~. 'Ll'"~..e · ~: (e r~ t: I::) (.:,:, ] c) w L cJl::~ o ~: c: a s i n g. A t a p u m p i n (.~ F' a t e o .f: 6 U a 1 ]. o r'~ % p e r m:i I'H. rE(.~ I::l"u,.:.~ wa'l:er 1 evel cli cl FIE)'J] cl"~al'~ge,, A 'Lot, al c)¥ U2',.'~; (?t~;~]. 1 or'i~E, ]'EST FOR E, COI..I AND 'TOTAl... NITROGEN: Wai::er [~:~ Cc:,l i O. 'l'c)'Eal Nit',r'c)g,~.::,r~ 2. '.:.:J mq/l . Max,, allow,?,b],F~ To'I:~T~I N:i. tr"oFlc.,H'l :J.O mo/l. TEST RESULTS: "1'1~ :i. s w~:~ 1 :I, m e:,~:.)'J"..s t'. I'i <:.~:, r' (:~ cI u i r" re, men I:: s cfi: i". I', (.,::, Mu n :i. c i p a :1. i t y o.F A n c h (:)t" ag (:.:',, CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION D,v s,oN oF E.V,RO.MENTAL HEALT. CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL._.__l"/,~'() - ]~3 .~'£[ OF ON-SITE SEWER AND WATER FACILITY 264-4720 GENERAL INFORMATION (a) Application Date Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name O"'~ m (~-"'C~'~ Telephone: Home ('¢~O~') ? 32 - ¢9¢'.~. Business Applicant Address _,~O ~ ('cn~c¢'cCr 6o~-'~'~,e," Dry,, ,~ t~¢'n,,, (.,'¢.~,,4 ¢~200 (c) Applicant is (check one): Lending institution []; Owner/builder D; Buyer []; Other [] (explain); (d) Lending Institution (,~-f~C Address ~ ( ~, ~(o~' (e) Real Estate Company and Agent Telephone (f) Mail the HAA to' the following address: 2. TYPE OF Single-Fam, ily [] Multi. Family [] Other Number Qf Bedrooms' '' 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 h'om the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84} 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. Name of Firm _ ~::(O: f~,/~'f 7~c~'~¢~:c~(' ~e~/c~/ Telephone 3Y~,~-~~ Address /~[~ L~C~¢ S~ ~ /~ ~ b¢~'~ ~(~ ~ff~l~ Engineer's Seal DHEP APPROVAL Approved for'~-,~ Approved Disapproved Conditional Terms of Conditional Approval CAUTION Tile 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 federat and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - F"EBRUARY 1984 264-4720 Legal Description: /..c~ (" WELL DATA Well Classification Well Log Present (Y/N) Total Depth '7~ ~ Static Water Level . ~? ~ Casing Height Above Ground '2_..O ~ Electrical Wiring in Conduit (Y/N) Y' Separation Distances from Well: To Septic/Holding Tank on Lot I ! O To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line i\{,,4., ~r'~v¢/-~ If A, B, C, D.E.C. Approved (Y/N) Y Date Completed ,~"/r~J/':¢¢~' Yield Cased to 7' ~ ' Depth of Grouting Pump Set At ':~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) tv' ; On Adjoining Lots ~> ~oo ; On Adjoining Lots ';-'> ~o ¢ To Nearest Public Sewer Cleanout/Manhole IN',/~t. To Nearest Sewer Service Line on Lot ~¥,/J · Water Sample Collected by Water Sample Test Results B. SEPTIC/HOLDING TANK DATA Date Installed ~-/11 t',¢i Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: Air-tight Caps (Y/N) NO, of Compartments ~- Foundation Cleanout (Y/N) '¢ Date Last Pumped ~'&/'¢-~ /~¢' ; for ~1, ~. Temporary Holding Tank Permit (Y/N) N, ~. To Water-Supply Well To Property Line '~ ¢O~ To Water Main/Service Line Course ~. foo ~ IlO~ To Building Foundation _ ;~2 ¢ To Disposal Field To Stream, Pond, Lake, or Major DrainCge Comments Page 1 of 2 72-026(11/84) /',AUNIcIPALiTY OF ANCHORAGE DEPT. OF HEAl. TH & ~NVIRONMENTAL PROTECTION RECEIVED C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed b--/If [ ~ ( Width of Field t:O ~ Square Feet of Absorption Area Depression over Field (Y/N) iN Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well I ~ To Building Foundation :~'¢' ' Lot ~ N, A. To Water Main/Service Line N~/~, To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments 7'~-e~'~c ~', ~-,'~ ¢-~'. ¢. Type of System Design 'T Length of Field ,.,¢0 ~ Depth of Field lO ~ Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Existing or Abandoned System on ; On Adjoining Lots r;~ .~ C' ~ TO Cutbank (if present) 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 all MOA and HAA guidelines in effect on the date of this inspection. Signed '"'~,~,,.~4._ ¢~. ~ Date Company Receipt No. Date of Payme~ Amount: $ Page 2 of 2 72-026 (11/84) THEODORE F, MOORE '. CE - 3589 Engineer's Seal I INSPECTION APPOINTMENTS DATE DATE ~, ~ DATE INSPECTOR iNSPECTORN ~t~: ~( ~-~t~' INSPECTOR~ MUNICIPALITY OF ANCHORAGE ~UNICiPALI~ OF ANCHORAGE  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTS. OF H':A~TH & 825 L Street - Anchorage, Alaska 9~501 ENVIRONMENTAL P~tOTECTION ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720JUl. REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND DIRECTIONS: Complete all parts on page 1. Incompleto requests will not be processed. Please allow ten (10) days for processing. 1, PROPERTY OWNER ~ PHONE Harry A. and Made!ine M. MackeyJ 688--281~ MAILING ADDgES8 St. Rt. // 2, ~ox ~' 6365~ Chugiak~ Alaska 9956~ PROPERTY RESIDENT (If different from show) PHONE James and Doro~hy Fish MAILINGADDRES8 Alaska Mutual Savings - Minnesota ~ranoh] 2'7/~ -2551 m~,U~S~DDS~SS (I W~[!i pick up approval - Madeline ) 5, LEGAL DESCRIPTION STREET LOCATION Lot 1, ~i Nettle'ton Aores ~ 2 Gormer o£ Abbot ~nd Homes%ead 6, TYPE OF RESIDENCE SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS E~] One [] Four E~ Two [] Five [~. Three [] Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * 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 10g if available.) 8, SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** lC)~1 __YEAR ON.SITE sYSTEM wAs INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) -~l/-/-2~O THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX I PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] I NDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY . ~ . {~ ,/ Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: ]%~--~'-") If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS Z~/~PPROV ED FOR ~--/~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) DATE BY 72-010 (Rev. 6/79)