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HomeMy WebLinkAboutSILVER CREST BLK 2 LT 9Silver Crest 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 ·" ' PH-C~NE I [] NEW NAME 349-'2316I [] UPGRADE ~IAI LING ADDRESS SRA Box 77M, Anchorage, Alaska 99507 LEGAL DESCRIPT~ON Lot 9, Block 2, Silvercrest subdivision NO, OF BEDROOMS LOCATION 4 Grover Drive and Lovitt Circle ~ ] wrel] Absorption'a'rea I~welling PERMIT NO, DISTANCE TO:I 100, 11, 17, 780180 O :Z Material No. of compartments I-- Z Manufacturer a..¢ Steel 2 ~ P Greer tiq, capacitv in gallons IF HOMEMADE: Inside length Width Liquid deptl] 1250 V~I Dwelling PERMI~F NO. ~, ~ DISTANCE TO: Liquid capacity in gallons Material ~z:~ Manufacturer , ..  Well Foundation Nearest lot line ~ERMIT NQ. '~' llO' 20' 29' 780180 D~STANCE TO: ~ No. of lines Length of each line Total length of lines Trench width Distance between lines ~ -- ~ ] 50 ~ 50 ~ 36inches Total effective absorption area ~ Top of tile to finish grade 60" Material beneath tile 60inches 500 sq, feet Length Width Depth PERMIT NO. ~ Total effective absorption area A p Type of crib Crib diameter Crib depth ~ Well Building foundation Nearest IoL line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT N6. ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: .~ PIPE MATERIALS A" plas¢ic pe~o~ate~ pipe ~/C,~. con~ec, ~01L TEST RATING ~ 120 ~q. ft. Der bedroom ' H & M ExcavatJ. n~~ REMARKS q~ '~ -A~PBOV ED DATE LEGAL L~ ~~/~ ~/~¢/Z~ Lot 9, Block 2, Silvercrost s~division 72-013 (Rev. 3/78) i"/;t; iq :I; I"1LIP'I D :[ ::;!;"l'l::ff.,IC:l:!; BETI,II:i:_'I:~ZI',! F:I HIEL..I... Fff-,l[) l::lhl'¢ O1'.,!-:~:.; Z t% SE(I.,.tI::I(;:itE D :[ ::~:;F'O:!i;F:I[ r. :i;i;"r':!!i;TEl't Z ::~; :;!.EIEI t::'.r:i:E'T 1::'O1:;;'. F:I t::'R;!;',,,'I:::!TE; I-4EI...L.* :!..r. ih3 TO ;;;!:EIE~ F'I::ZET .r::'l:;i'.Ol',t I::1 ~:;'t...IE',I.... ;!; i;;: I,.tI:i!ZL.L [)EF'ENI'):(I.4G UF'EIhl THE 'l"'.r'l::'E OF Pi JEIL.;[(;: !,.!!:~t...I i,.llEM... L.OG~!i; FI!:;,'E I:;;'.I:;{r;!U;(I;;'.E;t~:, F:tt'.,!D i-,tU~!i;T BE RETURNED TCI THE DEPI::!I:;~:Tr,IlENT 14:£'f'HIl'.,l )i:Ei Il)Fl-,.'::!; i;;71i::' "I"H[~; I,.!IEt...I.. COt',IPLET ): O1'.,I. O'f'!.llEt:;;'. t;',I.!iE.:!U ;( [;;'.E:f'IEI'.,!TS Flff'r' FIPPI.'T'. :SF'EC ;I; F' ~f CRT :!; ONS FIND I:::I',,,'I::I]:!...i:':IEd...E "1%1 Zl;t',!'.'2;I..Jt:~:[;i; F'I:;.:OPER M-W DRILLING, INC. DRILLING LOG Well Owner ' ~ Use of Well Location (address of: Township, Range, Section, if known; or distance main road Size of casing ___Depth of Hole feet Cased to feet Static water level Screen ( ); Perforated ( ). Describe screen or perforation ; Well pumping test at gallons per (hoUr) of drawdown from static level. Date of completion ft. (abOve) (below) land surface. Finish of well (check one) (minute) for ~ hours with open end WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness ); ft. TO .TO. TO. .TO. .TO. _TO _TO TO TO. TO TO. TO_ __TO .TO TO. 3--CONTRACI'OR DEPARTMENT OFH~LTH & HUMANSERVICES '.'Division-of Environmental se~ices On-Site Se~ices Section P.O, Box 196650 ~: Anchorage, Alaska ~ 99519-6650 '"":'- -' CERTIFICATE OF HEALTH AUTHORITY .: APPROVAL FORA SINGLE FAMILY DWELLING I I.D. ~ :' .............................. 1. ~'~ GENERAL= INFORMATION . ' ........ :,. .(,. ?~ ..................... - ,.... · .. . ............. - .... ' ~a, description ~?F..~;~omn'lete Lot 9; Blo Cr~t j~,~t~bcafion .-,~te address or directions) 9309. Grover Driv~ ,__ . :.~.~ ~;.,..--.,;,,;':/;~.~.- ..... . ....... . -. ,-.. · · ~-~!~! p~b~,; Owner' ~' G~ 8o4J ~ E~¢ ~/8oJJ Day phone ' ,~ ..; ~- ~';:J~;~ '.~.:.;,~T. ~ -. .'- .. :. '- - ., . . · : ....:':L . . · __,-;~. ,'~".~'~.'-Mailino address,,~-,', 9~09 O~ov~ ~v~ A~e~o~ AK 99516 ,- . ~;,.~z,~;~, ~.,..,, . .,"~.~' t' ~ '-' .' '-' '--"? -""---:':¢": '~':' ~'-'. ' ':"-':: ....... .~.,-%.i?':...- .... :: - · - - ,'~.. Mall o e .... 4~00 B S~g~ ~ 20~ .-A~e~o~g~, AK..?~50~ .- ., ..... - ....... n. addrpss .......... ~ ,.,. ..... ~,,~-z~. Aaent. ..... - ~,N.,...~-..., ....... .' .: ....- · :-.:~ :~-~: ~-~ 'm-'" - Day' phone"?r-;-, -.-... t-: ...,~_ .-. -.:~ ~ · ' .:. , . ~.',. NUMBER OF BEDROOMS. '. ........~;.?~ 3...-...~PE ~OF.,WATER SUPPLY. ".' ' · '-., ': " ,, ~';~...:;:~ NO~E:_.-_ If cd~muni~, well system, 'provide wri~en confirmation from'State A~EC a ' ' "' '~'t}'?; ', ;:~2~'~;,~ ,"'ing tb:the'legali~'and StatD~ of SYStem~, ~x.'.' ~-: :~:"~J~.';;~. ~¥;'}~h'[;:?': '. 4. ~PE OF WASTEWATER DISPOSAL -,.,..:.......:.--. ~, ~.~" , .. ~ r"-~,. ~ ' Holdlngtank ~., . , . .,~ . ~.. -~ .... , ..'g .'-~' ,,'?.-'" '. ''-'r~,--'.'': ...... , ---- .--.7--~:.;~.-"" ': ?"'~. -'';'""/t :' ~ ~: ' .' ¢[//r~'7'~ .... '~ .~')~3~" ~:;'¢'*¢~'~'' ',, '~" ';'~¢?Z~?~'~/:',~;,~' ~;~;['. 7'=' %.-'r?.'?i~'(~;~';'"t ?'' ':,'' .'- :~ ".""'. > ."' "'~'"= "", ~{ .':'~ NOTE If commum~ wastewater system, pro~t~ wrt~on ~nfirmattbn : '..: a~esting to the legah~ and status or system. ';' :'- '. As certified By my seal'~ffixed hereto ~nd as of the vahdabon date .qhow.n.b~IOw, I verify that my' investigation of this I..tealth'AUthodty ApProva~ application shows that tho on~site water supply and/or wastawater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated harain. I further verify that based c n the information obtained from the Municipality of Anchorage files and from my.!n.ves.t~ation and ins pection~ the on-site water supply and/or wastewat~r disposal system is in compliance with all Municipal and State codes, ordinances,· and regulatic ns in effect on the date of this inspection, i -,.... $ & $ ENGINEERING Phone ''~'~ Name of Firm 17034 E~II River LQOp ROid No. 2G4 · Address £~le River, Alask~ 995T~- .'::, Engineer'S'signature ~ . ~"~--~-- Date ''-~ The ~'L~n ~ parity oi:~nchorage Department"Of Health anC Human Services (DI-~H,~! issue, s Hea,!th.Auth?i~. A~proval Certifi,,c,ate~ based only upon the representations given in paragraph 5 ecove Dy an ~naepenaen[ '.,.'. professional eng'ineer registered in the State of Alaska. The DHH8 does this as a courtesy to purchasers of and their lending institutions in order to satisf7 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 omissionsi'n the professional en eets ~vork. . =, . .,~ :.= -:. ~t-: '- - ;'..Q':" :: ' ¢.:''"";';;~- . = . 72.(~5(Re~.1/~1) Back MOA~I Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825%" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343,-4744 Health Authority Approval Checklist LcgalDescription:LOz- q Bt, to ,,L F/~-,,'4:A C,,'¢/¢,sr 5/t> ParcelI.D.: A. WELL DATA Well type f°Rt Log present (('/_7/N) Y ~ .3 Total depth ) ~ O, ~' Sauitm7 seal (I~yN) x/~:. 3 Date of test Static water level If A, Bi or C, attach ADEC letter. ADEC water system number Date completed q' [' ~- / '7 ~' Cased to [ '3 O, f' ' Casing height (above ground) FROM WELL LOG I,,: Wires properly protected (~flN) V £ Y AT INSPECTION Well production .~- ¢~¢'~-,~,--.T¢¢.,0 fl Y WATER SAMPLE RESULTS: Coliform Date of sample: 68' '3c, O g.p.m. Nitrate ~ q. 6 d- .g.p.m. O, ! Other bacteria O Collected by: S & S ENGINEERING 17034 Eagle River Loop Ro~d No. 204 Eagle River, Aleske 99577 Number of Compartments ;L Cleanouts ~/N).__ Foundation dleanout (~/N) '4 r,~ .5 Depression (YO) ~ O High water alarm (Y~ PumPer t~ -k ¢or~{ 5(~,cc5' Date installed ¢ { ~q /7 ~ Soil rating(g...t) d IfC' o~fl-/od¢ I ~ O Lepgth ~- 0 t Width 3 Gravel thickness betow pipe. T- tt¢,.,,, oR System type. / / Total depth /o B. sEPTIC/H~ TANK DATA Date installed }f {3-q/'7 $ Tank size Effecti{,e absorptioii area Date of adequacy test c] Fhfid depth in absorption field before test (iu.); (~ Immediately aflerr--/~ 7_ gal. water added (in.): Fhfid depth q 5~, (ins.) Mitmtes later: ] -.~ Absorption rate = '(o O O '-}- g.p.d. Peroxide treatmeot (past 12 months) (Y/I~_ ,v e,,,4,_ k',-,o~, ~O If yes, give date .*~0 o er -t Monitoring Tube present(igYN) yt ~( Depression over field (Y/N) I 7 ] q,5-- Results (Pass/Fail) For __ Z/ bedrooms D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles~ Size ill gallons "Pump~ "Pump off' level at* .~*Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/tmld;.::g tank on lot Absorption field on lot Public sewer main Sewer/septic service line ; On adjacent lots ; On adjacent lols Public sewer mauhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/farGLDII',q~i TANK ON LOT TO: Building foundation ~ ! '/''- Property liue ,~ / -p' Absorption field ~'~ / /- Water main/service line / o / P- Surface ~w~ter/drainage / a o ~ / . Wells on adjacent lots / o o ~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation / o Surface water / o o ~ ~- Curtaiu drain ~,~,i- ENGINEER'S CERTIFICATION Water mai~ffservice line / O / -/~ Driveway, parking/vehicle storage area Wells on adjaceat lots /o0 / ¢~- Property liue /O HAA Fee $ ~ ~)~ ./ cJ~ Date of Payment '~/~ '~ /'~C~ Receipt Ntunber t/.~ //~ ./ Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Paymeut Receipt Number 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.# /(~\~ -' ~ - 1. GENERAL INFORMATION Complete legal description _ LoT HAA# ~ ~'~°~ Location (site address or directions) Property owner Mailing address Lending agency Mailing address. Agent. /'~/, ~r, Day phone Day phone Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State AD£C attest- ing to the legality and status of system. 4. TYPE OFWASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEO attesting to the legality and status of system. 72-025 (Rev, 1/91} Front MOA ¢121 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. NameofFirm FZATTO? T~,cI.t £VC~q Phone 3 Address Iq53o Ec~o ST, A~C~. A~ ~/~ ~~ ¢ ~ Date Engineer's signature DHHS SIGNATURE ~" Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments II IIII III I 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 engineeCs work. 72q325 (Rev. 1/9t) Back MOAfl21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: LoTcL, Bzk'=., 5/L~/r_,P(",¢,¢S7 5ua Parcell. D. 0,'~--- o ~ ;,_ - L-,Zo A. Well Data Well type PFj v'A TE' If A. B, or C. attach ADEC letter. ADEC water system number Log present (Y/N) "/ Date completed ¢J l l£/-/8 Total depth 13o, 5' Cased to I '5o. ~- Sanitary seal (Y/N) "/ Date of test Static water level Well flow Pump level1 FROM WELL LOG ,2__O SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Io~' T~ C.,0. Absorption field on lot 11'4' T~ E.O. Public sewer main N,A. Sewer service line ~ 5' Casing height Wires properly protected (Y/N) Y AT INSPECTION 5'(0 ; On adjacent lots ; On adjacent lots >/oo Public sewer manhole/cleanout ~ .A. Petroleum tank WATER SAMPLE RESULTS: Coliform 43 cc,( /~,oo ra~ Date of sample: '7/30/% Nitrate ~, ,¢. I ,,,~,,~ f/-¢- Other bacteria Collected by: FZ/)T7oP TEd/-/. 5~5', B. SEPTIC/HOLDING TANK DATA Date installed ~/'/'g Cleanouts (Y/N) ¥ High water alarm (Y/N) Date of pumping Tank size 1250 Foundation cleanout (Y/N) ~4c Compadments 2_ V' Depression (Y/N) Alarm tested (Y/N) J',/./~, Pumper N SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot J OL+ Fe~ C.O, On adjacent lots To property line ~ 2o Absorption field Sudace water/drainage ~. /oo ' Foundation Water main/service line '~' ~/o 72-026(3~93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at 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 ~/'/3 Length ~-o Width Total absorption area 5oo Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/F¢) Gravel thickness Cleanout present (Y/N) Results (pass/fail) O .System type T~'~C/~ ~,o" Total depth ~ o Depression over field (Y/N) 1'.4 for ~ Bedrooms After test O If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I I ~/ To building foundation On adjacent lots ~> Surface water '>-/o Curtain drain On adjacent lots ~> /oo Property line To existing or abandoned system on lot Cutbank N. 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 e#A¢.~t.~.e~.date of this inspection. Signature ~~ ~ ~ '~ .......... EngineeCs Name ~4~ ~. ~r¢ '¢ ~ ~H:ouol:~ ~. ~oo~ · ~ ~ "~¢~'. CE-3589 .,~ll HAA Fee $ Date of Payment Receipt Number 72-026 (3'93)* Back Waiver Fee $ Date of Payment Receipt Number ENGINEERING FIRM PROVIDI~' !NSPECTIONS, TESTS, FILE SEARCH, D ~. AND INFORMATIOI'~. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation o! 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 Anchora,ge flies 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 F~!,~. RT'~/~;R ~kTP, ThJ~'~.RTN'P. RF~R~Fr'P~,q Address P_~. ~ 77~P~, ~A~T,~ ~, AT,A~fl Date ~/= ~/~ ~ Telephone 694-5195 99577 Seal DHEP APPROVAL ,/~,~// Approved for ¢ bedrooms by ~ Date ¢-,2 ~"-- ~ ~' Approved ~ Disapproved Conditional Terms of Conditional Approval 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 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 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) ~NVIRONMEN'CAL ~ERV)CE,S DIVISION RECEIV 'D WELL DATA MUNICIPALITY OF ANCHORAGE (MO. HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal ,Description: ~ -;"- Well Classification /'¢¢3 1 &~l 7-~ If A, B, C, D.E.C. Approved (Y/N) '/~' Well Log Present (Y/N) Y Date Completed ~/~-?/~ Yield ~, .~- d-,'~,'~ Casing Height Above Ground /z/ Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot //z'? / To Nearest Public Sewer Line /"//~ Cleanout/Manhole Water Sample Collected by ~'~5 Water Sample Test Results ~¢~~..~.-- Comments Depth of Grouting Pump Set At /-/-~ ~¢ V Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ¢'/~'~ / 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) ~ __ Air-tight Caps (Y/N) Depression over Tank (Y/N) 4/' Pumping/Maintenance Contract on File (Y/N) '~/"~ Holding Tank High-Water Alarm (Y/N) "'~ Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line Z ~',2~, ' To Water Main/Service Line "/' Course Size /~..5-¢ ~,¢)~/ No. of Compartments ~ Foundation Cleanout (Y/N) ~ Date Last Pumped ~,"./,~o/~'? ; for -~ - Temporary Holding Tank Permit (Y/N) ~ To Building Foundation J To Disposal Field // To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 72-026(11/84) C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ?~' ?°c Width of Field '~'~ ''/ Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test ~"~ Separation Distance from Absorption Field: To Water-Supply Well /iz¢ ' To Building Foundation /.2. Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design 7-;'"¢ -,"~ Length of Field ~,~'-o Depth of Field /~ Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test ~_,-~.-~/'~;~ To Property Line /~-"- To Existing or Abandoned System on On Adjoining Lots ~' 3~ / 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 ~~ Date Company ~x¢£ MOA No. Receipt No. ~ ~/-- Date of Payment ¢ Seal Amount: $ ./~ ~ Page 2 of 2 72-026 (11t84j MUNICIPALI'rY OF ANCHORAGE DEPT. O; ~.' ,".L¢ll & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTi~VIRON/,: ,qT,'XL ~,,' .'LCTION  825 L Street - Anchorage, Alaska 99501 r E.WRO. E.TAL E.G .EERm mWSm. MAR Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES 31RECTIONS: Complete all parts on page 1. Incomplete reqaests will not be processed. Please allow ten (I0} days for processing. 1. PROPERTY OWNER ~ ~ , PHONE MAILING ADDRESS PROPERTY RESIDENT (if different from above) PHONE ~ PHON~ ~AILING ADDRESS ~- PHONE ~AILING ADDRESB 4. REALTOR/AGENT ~. ' [ PHONE' ~AILING ADDRESS 5, LEGAL DESCRIPTION ~/~' TREET LOCATION r .3% 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One ~1 SINGLE FAMILY [] Two [~] Five [] V~U LTIPLE FAMILY [] Three I~ Six 7. WATER SUPPLY IN[)IVlDUAL~ [] COMMUNITY [] PUBLIC UTILITY [] Other *ATTACH WELL LOG, A well log ~s required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attacl~ log if available,) 8. SEWAGE DISPOSAL SYSTEM ~. INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY *' If individual/on-site, give ~nstallatmn date ..__~) If system is over two I2) years old an adequacy test is requ red by this Department, NOTE'. THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-01013/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS ~ SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO -ELI FOUR [] SIX 2. WATER SUPPLY PERMIT NUMBER ~ INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY ©l- Connection Verified LOG RECEIVED 3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER ~ INDIVl 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 Absorption Area ISewer Line I Nearest Lot Line WELL TO: I Absorption Area to nearest Lot Line 5, COMETS , ~PROVED FOR ~ BEDROOMS ~ CONDITIONAL APPROVAL (letter~t accompany certificate) ~DISAPPROVED E_~~/ / LEGAL DESCRIPTION 72-010 (Rev, 3/78)