HomeMy WebLinkAboutSKYWAY PARK ESTATES BLK 6 LT 13
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COSA Checklist WELL ONLY.docx
COSA Checklist
Legal Description: SKYWAY PARK ESTATES BLOCK 6, LOT 13 Parcel ID: 019-151-24
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled CIRCA 1971 Total depth 57.5 ft
Cased to 57.5 ft (DATA PER MOA RECORDS)
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 5/28/2024
Static water level at beginning of test 47 ft.
Well production at time of test 2+ gpm
Water storage tank volume NONE gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 0.634 mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by Date 5/22/24
Comments __________________________________________________________________________________
B. TANK DATA – PUBLIC SEWER
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA - PUBLIC SEWER
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist WELL ONLY.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No NA ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No NA ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
G. CERTIFICATION & 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, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 5/31/24
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
05/31/24
50'
ANCHORAGE RECORDING DISTRICT., ALASKA
AS -BUILT OF:
SKYWAY PARK ESTATES
LOT 13 BLOCK 6 PLAT P-632
SURVEY CERTIFICATE: 1, John L. Schuller, Have conducted a
physical survey of this property as shown on this drawing and that the
improvements situated hereon are within the property lines and no
enchroachments exist other than noted. Under no circumstance shoul(
any information on this drawing be used for construction of fences,
structures, improvements, or for establishing boundary lines.
EXCLUSION NOTES: It is the owners responsibility to determine
the existence of any casements, covenants, or restrictions which
do not appear on the recorded subdivision plat.
WORK ORDER NUMBER: DAIE- SCALE, E-MAIL
JULY 19, 2024 1 =50' schullerakOgmail.com
24-074 DRAM BY: 10iECKED BY; GRID NUMBER: TBOOK PAGE:
JLS SW2729 240243
0 = FND I" IRON PIPE
* = FND 5/8 " REBAR
4W
low
40,400 0 F
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49TH .7 ?A _-Z7 112D
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P I•* Oi
JqHN L. S CHULLER.- 0 A0 1 :
LS -10408 �41
1831 Talkeetna Street
Anchorage, Alaska 99508
essiono\ (907) 227-1455 office
(907) 274-4992 fax
M
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.# O1~- t /
1. GENERAL INFORMATION
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
NAA# ~ ~0~ ~/_~ ~0\
Complete legal description
Lot 13; Block 6; Skyway Park Estates
Location (site address or directions
Property owner
Mailing address
Leon Janis
1441 Shore Drive
Anchorage, AK
1441 Shore Drive
Anchorage,
Day phone 349-3200
AK 99515
Lending agency
Mailing address '"4~'.. ¢'
Day phone
Agent
Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: - $ '~
TYPE OF WATER SUPPLY:
individual well xxx
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX -
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-O25 (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.
Name of Firm
Address
Engineer's signature
S & $ ENGINEERING
.... -' '-"s~ R;wr Loop ~oad I~o. 204
Eagle River, AlasEa g9577
Phone
Date I,/ 3 / <~ 7
D~/S SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Hur:::- ;Services '"S) issues Health Authority
Approval Certificates based only upon the representations given in paragr: ' above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as r::. ,:'-'esyt¢ purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirem~;ts. Employees of DHHS do not
conduct inspebtions 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.
N~UNK4P.&LII'Y Ok
~N¥IRONMENI'AL SERVICES OlYJSlON
IOV
Municipality of Anchorage C
DEPAFITME!NT OF HEALTH & HUlVIAN SEFIVIGE$
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907] 343-4744
Health Authority Approval Checklist
L.egalDescription: Lo7 I~ /~L~ (~ ..~'//--y~4. y fM/~: £~';,'. ParcelI.D.: O/¢J 4:&-~::-7 -~ / --
A. WELL DATA
Well type P
Log present (Y/~ ~ 0
Total depth ~" -~ '/:z
Sanitary seal ~/N) Y.~
IfA. B, or C, attach ADEC letter. ADEC water symem number
Date completed u I ¢<
Cased to ,¢'- ~ '/~ ' Casing height (above ground)
Wires erooerly protected
FROM WELL LOG
Date of test
Static water level
Well production
g,p,rr
AT iNSPECTION
g,p.m
WATER SAMPLE RESULTS:
Coliform
Nitrate
O · / Other bacteria
Date of sample: / O 3 '7 / R 7
B. SEPTIC/HOLDING TANK DATA
Cate installed
Foundation cleanout (WN)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Length Width
Tank size
Deoression (WN)
Pumper
$ & $ ENGINEERING
Collected by: '~7034-E~e RJwr Lu,..,p R~u, ' .7.,,
~ r~ ~ ~ ~ Eagle River, Alaska 99577
Sum~oro~Compa~monts __ Oloa~)
High watSon)N)
Soil rating (~F'J~./fl~ or fF/bdrm) System type
~ Oravel thickness below pipe Total deot~
Effective a~sorption aree .~ Monitodng Tube present (Wlq). . Depression over field (¥/~1 ---
Date of adequacy~ Results [Pass/Fail) For
Fluid de. absorption field before test (In.); Imrnedlately after_
F.~6pth _ (ins) Minutes later: Absorption rate =
,/Peroxide treatment (past 12 months) (Y/N)
gm. water addeo (in.):
if yes, give date
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallo.~ns ~
Manhole/Access (Y/N) ~el at* "Pump off" level at*
High wa~ ~Datum
C~sted
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELLON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation Property line Absorption field ~
Water main/service line Surface water/drainage ~ent lots
SEPARATION DISTANCE FROM ABS~:
Property line ..4~ng founda'don Water main/service line
Surface w.a.~~ Driveway, parking/vehicle storage area
C ~g~n drain Wells on adjacent lots
K
ENGINEER'S CERTIFICATION
·
I certify that I have determined thru field inspections and review of Municipal re~.~Ptft¢'~bove systems are
in conformance with. MOA H&A guidelines in effect on this date. ~ ~ ~¢ ~ -
Signature
Engineer s Name /4 0~, . 0~ ~
HAAFee $ r~ ~ '~¢''~ WaiverFee$
Receipt Number
72-026 (Rev. 3/96)*
Date of Payment
Receipt Number
0CT-30-1997 10:13 CT&E ESI ANCHORAGE
~¢~/~ CT&E Envi,onmental Services Ino.
90?5615301
P.03×05
CT&E ReL#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
~ple Remarks:
97661(:002
S & S Engin~r~g
N/A
Lot 13 Blk 6. Skyway Park l~6t
Drinking Water
0
Client
Printed Date/Time 10/29/97 13:07
ColleOedDate/Time 10/27/97 10::30
Received Dale/Time 10/27/97 16:15
T~:lmical Director: Stephen C, Ede
ReSU[t$ POL
~{trate-H 0,100 U 0.100 molL EPA 30U.O 10 mu~ 10/27/97 GCP
Iota[ Coliform 1 OD/ 100 mi/ NO ¢OLI $~18 92228 I0/2¥197 T~U
MUNIC(PALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF iNSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # _("~ t~ -
1. GENERAL iNFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner ht~-'"~'~Y
Mailing Address .
(c) Lending institution .P¢c
Mailing Address -
(d) Real Estate Company and Agent
Address '~ o'"O ~
Telephone.: (home) ~ Yq-/°d'V. Business ."¢¢l-
Telephone 9~ 7¥ - ~So/
,,4-,,
Telephone
t'7~f-
(e) Mail the HAA to the following address: (or check here (~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family I~ Number of bedrooms
3. WATER SUPPLY
Individual Well [] Community [] Public []
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 El
Nole: 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
5. 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 th is
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 fifes 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/'¢,? 7-~o6n~,¢,~/
Address I
Date
~g"'~'~'¢'"'~ Telephone '3' 5',5-- / ~',.4"5-'
6. DHHS APPROVAL
Approved for z~-
Approved. ~
/
Disapproved . Oonditional
Terms of Oondition~l Approval.
Engineer's Seal
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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.
(~-,~ MUNICIPAL, ITY OF ANCHORAGE (MOA) ti~^u f,,, 0~ ?,~l~h~,j~{~hority Approval (HAA)
343-4744
;,, ~ ~,', Legal Description: ~ I~.
A, WELL DATA
Well Classification
Well Log Present (Y/N) iV Date Completed ~ t? '7J
Total Depth~.~7,%_ Cased to ..c'?,.,,- Depth of Grouting --
If A, B, C, D.E.C. Approved (Y/N). I/l'/]''
Yield :7, ~'7 ~/~'~, rnec,4 I~1'//~'?
Static Water Level
Pump Set At
Casing Height Above Ground /~"¢'
Electrical Wiring in Conduit (Y/N) _
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot __ N,.¢. ; On Adjoining Lots
To Nearest Public Sewer Line ;:> IO0 ' _ To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ~ '8,5- '
Water Sample Collected by F~lcx/'f°l'~ 'F'cc/~ ~/cu' ;Date
Water Sample Test Results ¢. ~/ m~ / ~ ~ -~., ~
Comments Cfc~ I~~g o~ If( ~5 ~ ~r~ ~2
~/ ~((o~-~ -¢~l~1~ ~o~ ~o ~¢~/-~i~
B. 8BPTIC/HOLDING TANK DATA N. ~.
Size _ No. of Compartments
Air-tight Caps (Y/N)
Foundation Cleanout (Y/N)
Date Installed
I::)ate Last Pumped
; for
_ Temporary Holding Tank Permit (Y/N) ~
Standpipes (Y/N)
Depression over Tank (Y/N)
To Building Foundation
To Disposal Field
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N) _
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line _
To Water Main/Service Line _
To Stream, Pond, Lake or Major Drainage Course
Comments ~/¢r,~l~ Co/~n ¢ciLr-on ~
72-026 (Rev. 7/88) ~ront Page 1 of 2
C. ABSORPTIONFIELDDATA
Soils Rating in Absorption Strata
Datelnstalled
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments 6.'~'~ ('o~,~-~c.,q,o,o /~, ,4uJu...,¢c
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
D. LIFT STATION N,/)-.
Date Instarled
Size in Gallons
"Pump On" Level at
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 Cycle8 during Adequacy Test,
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked verified, or conformed to all MOA and HAA gui~g~,i~s~in effect on the date of this
inspection.
Signed_ .c7-~ ,¢jC,, ").'/~ _.~,,~C~:. ....... ,~.,,,d,~,~
Company_
Date / ~./ re / a? ~"...~)"- ............... ~o~.~ Eng,neer'e Sea~
(?0 ~";¢' '" "" '~"'
Receipt No,_
Date of Payment _,",~
Amount: $ ,/,~2~"? ' ~'~f~ Date of Payment
72-026 (Rev. 7/88} 8ack Page 2 of 2
5633 13 STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
FEDERAL TAX ID ~ 92-0040440
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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
GENERAL INFORMATION
(a)
(b)
(c)
Application Date
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions) ¢
Applicant AddresCfs ' ~~~4 ' . .-
Applicant is (check one): Lending Institution ~; Owner/builder; Buyer D; Other ~ (explain);
(d) I_ending Institution _[.~-.~_~,,t/~_~r_/~¢¢/,~
Address' '~-'--' -~" "~-'</~/_~?¢~)
(e) Real Estate Company and Agent
Address
Telephone
Telephone
(f) Mail the HAA to the following addr~s,~
TYPE OF RESIDENCE
Single-Family/~ Multi-Family []
Number of Bedrooms 4
Other
WATER SUPPLY
Individual Well..J~[ Community IF] 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 F1 Public~ Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status,
Page 1 of 2 72-025 (15/84}
ENGINEERING FIRM PROVIDIN,~i INSPECTIONS, TESTS, FILE SEARCH, D/~ ~A AND INFORMATION
As cedified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval sl~ows that the on-site water supply and/or wastewater disposal system is safe, functiona 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. / ,~"4~'~ Telephone
Address Z~ h/
Engineer's Seal
Approved for_ ,/~;~!~Z~_ bedrooms by ./~k'vv'
Approved [.~'~'~" Disapprover~/
Yerms of ConOitional Approval
CAUTION
The MuncJpality 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 DNEP 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
?'2-025 (11/84)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICIPALITY OF ANCliO~Ao]
[)Et]]'. OF H~AL]tl &
.ENVIRONMENTAL f,,O[E£ IIOhl
Well Log Present (Y/N) /~ Date Completed _~., , -, ,~ Yield
Static Water Level ~.~ ~ PumP Set At /~.¢~¢,-'.r"i4~
Casing Height Above Ground ,_,~ ~ Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit [Y/N) ~ Depresmon Around Wellhead (Y/N)
Separation Distances from Well
To Septic/Holding Tank on Lot ~//~ : On Adjoining Lots ~
To Nearest Edge of Absorption Field on Lot ~/~ ;On *clio,Ring Lota .~/~
To Nearest Public Sewer Line ~/~ ¢
, TO Nearest Public Sewer
Cleanout/Manhole ).~ I To Nearest Sewer Service Line on Lot
Water Sample Collected by _ ~ ~/~.&~ Date ~/~
Water Sample ]~ Results --~/~¢~F
SEPTIC/HOLDING TANK DATA
Date Installed
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:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
S ze No, of Compartments
Air-tight Caps (Y/N) __ Foundation Cleanout (Y/N) _
Date Last Purr pea
for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream. Pond. Lake. or Major Drainage
Comments
Page 1 of 2
/
ABSORPTION FIELD DATA /~/,~
Soils Rating in Absorption Strata
Date Installed
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
To Building Foundation
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
Length of Field
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
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 ce r ti f Y t h at~c h %~,~e~ ~r~fled,
Signed
Company
or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Date
MOA No.
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 {11/84)
Engineer's Seal
~~ ,GREATER ANCHORAGE AREA BOROUGH
II/// Department of Environmental Quality
~~ 3330 "C" Street, Anchorage, Alaska 99503 274-4561
~ \~ x~l,~ Date Received
~ ~' ~ REQUEST FOR APPROVAL OF
~X ' TM ~ INOIVIDUAL SEWER & WATER FACILITIES
X ~ FOR
1. Approval requested by:
Mailing Address:
2. Property Owner:
Mailing Address:
3. Legal Description:
Phone: .~?Y-'?~//
Phone: ~/~-e~¢~
~f~ ,~ ~ _:~_~ .......... ,
~ype o~ ~ac~ity ~o ~e i~spe~te~ _m-~/~_~ ~o. o~ ~e~rooms __'/
Well Data:
A. Type ,~A~c~ , B. Depth ~-~-~r~' /
C. Construction
D. Bacterial Analysis
7. Sewage Disposal System:
A. Installed B. Installer
C. Septic Tank: 1. Size 2. Manufacturer
D. Seepage Pit: 1. Absorption Area 2. Material
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank , Absorption area , Sewer Lines ___,
Nearest lot line
, Other contamination
B. Foundation to septic tank
, Absorption area
C. Absorption area to nearest lot line
EQ-034 (1/7~) Page 1 of two pages
I90 FrUiT