HomeMy WebLinkAboutSKYWAY PARK ESTATES BLK 8 LT 15
Sep_20.2022 05:36 PM Anchorage Well & Pump Service Inc 9072430742 #0542 P 1/ 1
MUNICIPALITY OF ANCHORAGE
Development Services Department * Awl Phone: 907-343-7904
On -Site Water & Wastewater Section s Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: Date of Issue: - -
Parcel Identification Number: 019 _102 _ 10
Legal Description Block Lot Propeity Owner Name & Address:
DOKOO�IAN JIM & DENCY FAM TRST
SKYWAY PARK ESTATES 8 15 DOKOOZIAN JAMES P & DENCY R 1 TRUSTEES
1740 SHORE DRIVE
ANCHORAGE, AK 99515
Pump Installation Date: 09 - 12 - 2022
Pump Intake Depth Below Top of Well Casing: 94 feet
Pump Manufacturer's Name: XYLEM
Pump Model: 12S8
PumSize: .50 h
Pump p
Pitless Adapter Burial Depth: 10
II Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer:
feet
MARTIN ON
Well Disinfected Upon Completion? )( Yes ❑ No
Method of Disinfection: PELLETS
1 Comments:
Pump Installer Name: .
ANCHORAGE WELL & PUMP SERVICE
Company: 7640 KING STREET
ANCHORAGE, AK 99518
Mailing Address: 907-243-0740
State;
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
rv'J-VV DRILLING, Inc.
P.O. Box 10-378 · 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511
DRILLING LOG
Well Owner MICHAEL B, BERGMANN UseofWell Domestic
Location (address of: Township, Range, Section, if known; or distance main road Lot 15 Block 8 Skyway Park Estates
Size of casing fi" Depth of Hole_58 feet Cased to. 57.5 -feet
Static water level 45 ft. (M~xm) (below) land surface. Finish of well (check one)
Screen ( ); Perforated ( ). b/~/L(~
(minute) for
Describe screen or perforation
Well pumping test at IS__gallons per Omm'~
of drawdown from static level.
Date of completion November 30: l_983
open end ( XIGX );
1 hours with ! 001
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
0 .TO 2 .
2 TO 41
4 i__TO 50
50 TO_ 58
__ .TO
__ TO
__ TO
___TO
__ TO
TO
__ TO
__ TO
TO
__TO
Ca~:lng .... l.up
Silty gravel & cobbles
Clean s~nd
Water~a~Ling_~andy gr~azel.
1--CUSTOMER
PIERMIT NO.
E..EI F~.7 1 IE.I I I L.. HEi::ILTH FII",I[:' [:l ,I ~ I I..L 141 II::..I-,I FML , . , . .
~-.Jl IEC: I1_. t[-- IF::" lEE [F;;~:: ~'""] ~_- 'T
(',3]:0'.i;~47 ';,
I::IF'PL..ICI:::INT MIC:HI:::IEL. B. E:EFb]iHRI",Ihl BO',:':; J. 9::l.., 51:~:1':'~, FII",ICtrIOF'.R[~iE fll...lUlSKl::l
i...OCRT I ON
[..E(]i[;:lL CElT ::L5 E:I...K 8 ',~;l<"¢!.4Fl"r' I::'F:II';~:I'( LOT SIZE 9999~.-T~9
SQLIFIRE FEE'I*
i'IIf',IIMLIH [:'I:STRNCE BETI.,.IIEEt",I FI I.,.IE!]....L. FIN[:' I::11%" ON-:E;ITIE L:;EI.,IFIGE DI2;F:'O~SFII_ '..=.;'¢STEI'"I I2~;
:1.O0 FEET I:::'OR FI F'F~'.I',,,'FITE 1.4ELL. OR :i..50 TO ;E'OC, FEE:T I::ROH R F'IJE:LIC NE:I_L. [)EPEI",IE:,ING
UPON THE T"r'F'E CIF I::'UEd~_:[C I,.IEL[ ....
I'"IINIHUI'I [) ]: ~!;T~::II'.,II];[~ I::;'ROI'I FI f::'I:~:I',,,'FITE: I.qEI_L TO FI F'F;?.]~',,,'I::ITE f~;E[,rIEF;: L. INE Z'.5 2.5 FEET F:II'.,IC,
TO F:I COI'IMLINIT'./ '.i~;IEI.,.IE,:~: L. I IqE :IS 75 F'EET.
I,.IEI.J... I....C~GS I"-'I[;:E I::,:E6¢..IIF~:EL], FINE:, I"IUS]' 13E RETURNEE:, TO 'THE DEF'RR]'MEI",IT WITHIN ::~:E) [:,FI"/S
OF THE WELL COHF'I..F:TION.
OTHER [;?.E~]!LI I REMIEI',I]"':':; HFI¥ IqF:I':'L"r'. SF'EC); FI CFIT IONS 1::Il'qb CONSTRUCT I ON D'[ I::IGRRMS FIRE
W,,;FI];LRE~LE TO INSURE I::'I:;b]F'EI:~: INSTFILLR"I'ION.
I CERTIFY THFIT
::L: I FIM FFIHZt...IFff;'. HITH THE F.:E6K]IREI'IEI'¥T':5 FOR ON-L¥ITE SEI.qERS FIND I,.IELLS F~S SET
2"CI1~:-I'1-1 EP¢ THE MLINICIF'F'IL. IT'¢ (::iF: I::II'.,]C:HOF,~FIGE.
;?.: .1.' WIL.I.... INSTFILL THE S'.r'E;TEM IN I'.:ICCCIRDFII'.,ICE I,.IZTH ]"HE CO[:,E:E;.
V4. 0
.,j
)
FI1CHAI~ L D.
ll'IUI4. DI_~.TFIIIC. E £:[.'i't,JEEN n I,II-.L.L FJNP ~li',l'~' OI'I'~5-]TE ~EHFtGE DI_qF'O.c,(~,L '-
.~'3- FaF: FI r-re., ~'~ HELl_ OR '.150 lC, 2E*o FEEl' FF.'OIf fl FUDLI.. HELL
'~"~H~, 'I't'F'E OF F'UE;L]£. HLI. L.
LOG% i:t~:E I~EOLIIRED I~H[., 1,1LLC,'i E,[ RETL~,~I.IED TO '[Hf~ DI~Fa,Rll,tF.;N'[ I,IIlHIN
Irt{E ~dELl £:AI'IF'I~ETICN
-~ I~[f,_llkEl,IEf.l'i£. ft,q~' flF'PL.Y, 5F'ECIFI£.FI'/]OI.t£. P,N[~ C:OhlSTFIUC:t'lOI',~ DIFIC~Ft[,1S
ILFiDLE )'r, ]NS. LII~;D F'F.;OF'EF~ II.LcT[FILLF, i'I ION.
MUNICIPALITY 0FANCFIORAGE · ·
DEPARTMENT OF HEALTH & HUMAN SERVICES.
Division of Environmental Services ~
. On-Site Services Section .
PiO. Box 196650 .Anchorage,'Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) 17~0 -C,~o~'~ Or~'-¢
Property owner _ 'T'~.rT'?
Mailing address _ 1700
I_ending agency_ ~.y
Day phone
'~.r/¢--.) _ Day phone
Mailing address_
Agent __.~m
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE 0FWATER SUPPLY: '
Individual well
' ~ ' COmmunity well ....
Public water
w
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAl.: ,
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
12-025 [Rev. 1/91) Front ~OA
If community was~ewater system, provide written confirmation from State ADEC
attesting to the legality and statue of system.' ' '~ ""' ~ ~
' '!. '" "'%' ~ : :'.~'-i, -'.." - -
:':'.;: .~'L'. ',:"
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verity 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 n L~mberof bedrooms
and type of structure indicated herein, 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 ~/~/',/~/¢ 7'~cAnlc~!
Address I ~/,,c-~ r_~
EngineeCs signature '~~
DHHS SIGNATURE
' ~ Approves for rx bedrooms.
Disapprove~
~*- Conditional approval for
Phone
Date
Additional Comments '~'~
TAMP
bedrooms, with the following stipulations:
The Municipality of A, nchorage Department of Health and Human Services CDHHS) issdes Health Authc~HtY
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 d0'~i0t '
conduct Inspections or analyze data before a certificate is issued. The Municipality '0
;. responsible for errors or omissions in the professional engineer's work.
,:, ~;:,~:~: , ,:.;, ~: '., ..,~: :?, >'~ , ,' ,;.
Municipality of Anchorage
Depar[ment of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:. L tS) GIh: ~., .~t~,yu-.~), t~'arlr ~s ~. Parcel I.D,
A. Well Data
Well type /¢'F~ ~'¢/-~'
Log present (Y/N) Y'
Total depth ,5-& '
Sanitary seal (Y/N) '('
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed. / ~ /.'~o / ,¢_~ Driller /~ -. ~
Cased to ,,~ % b-' Casing height ! ¢"
Wires properly protected (Y/N) .... Y
Date of test
Static water level
Well flow
Pump level1
FROM WI=LL LOG AT INSPECTION
I-5' g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
Iq, A'.
; On adjacent lots > too '
; On adjacent lots .> too,
Public sewer manhole/cleanout -,> ?_oo '
Petroleum tank _ I'\lo,~e 5' 4'~.~
WATER SAMPLE RESULTS:
Coliform 0 col /¢0o ,r,/
Date of sample: ~/~t /¢¢
Nitrate
Collected by:
B. SEPTIC/HOLDING TANK DATA fY.
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size Cornpadments
Foundation cleanout (Y/N) Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES I-'ROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Sudace water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (8/93)° Front CONTINUED ON BACK PAGE
C. LIFT STATION /XI, ,4,
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length
Total absorption area
Date of adequacy test
Width
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Soil rating (GPD/FF)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot On adjacent lots
To building foundation
On adjacent lots
Sudace water
Curtain drain
E. ENGINEER'S CERTIFICATION
Sudace water
System type
Total depth
Depression over field (Y/N)
for
After test
If yes, give date
Proper~y line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
Bedrooms
of this inspection.
I certify that I have checked, verified, or conformed to all MOA and HAA g
Signature ,~~
Engineer's Name
Date _(' ¢/0 /- ~ ,~
CE - 358'2
HAA Fee $
Date of Payment
Receipt Number
72-026 (3/93)" Back
Waiver Fee $
Date of Payment
Receipt Number
09?02×94 15:58 CTgE ENUIRONHENTOL LRB SERUICES ->~451355 NO. 300 ~0~)
NI.airlx
Commercial Testing & Engineering Co,
Environmental Laboratory Services
LABORATORY ANALYSIS RI'_-PORT
1518 SKYWAY PARK EST S, }lOSE BIB
WATBR
Clieltt Name FI,ATYOP TECHNICAL 8B.V W OI;,,K Order 81796
Ordered By Printed Date 09/02/94 (~), [2:54 lu'$.
Projcut Natne CollcctedDate 08/3 [/94 (q}09:00
Proj¢ot# Reeelvcd Dale 08/31/94 (a'.') 09:30
pWSID UA
Technical Dirc,Aor STEPIIEN C, EDE
QC Allowable Ext, Anal
Parameter Rcuulla Qua[ l.}lfii.q Method limits Dab Dste Init
.......................................... ~,i§ ............ iWg/~; ........ ff, XTfi~{3~67 ..... ~ ................ ~67¢i--~§ ....
N trait-N:,
* ,.qe~ Speeia[ It~struofioxt,s Ab ove UA ~ Unavailable
** Sm Sa nplc Remarks Above NA =Not ~t~yz*d
. U = Un~to~te~ Rc?o~edvah~ is thepmutical ~mflilicatjon limit. 1/i'= l~ss ]halt
~'s D = Seeom[~ry ~lution, ~= (~,eatcr~tal~
5633 B Street, Anchoragu, AK 99B18-1600 -- Toh {907) 562-2343 Fox: (907) $61-5301
ENVIRONMENTAL FACILITIES IN ALASKA. COLORADO, FLORIDA, ILLINOIS, MARY~ND, NEW JERSEY, OHIO, UTAH, WE$T VIRGINIA
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AN[) WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directioas)
(b) Property owner j"/~c/~czE,(
Mailing Address 1 '700
(c) Lending Institution
Mailing Address [0 [
(d) Real Estate Company and Agent
Address. ~0~
Telephone ~ 7~ -
Telephone: (home) "~ ¥/¢'-~/5'Z2 Business __
~'[~ ~ Telephone
(e) Mail the HAA to the following address: (or check herein, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family [] Number of bedrooms
3. WAI'ER SUPPLY
Individual Well [~
Community [] Public [3
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [] Public ~ Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-02S (Re~ 7/88) Page 1 of 2
~ to ~ e§ed
'~o~ s,Jeeu!Due IBUO!SseloJd eql u!
suo!ss!uuo Jo sJoJJe Jo¢, elq!suodseJ lou s! e§eJoMou¥ ,~o/q!led!o!u n~ eLI£ 'penss! s! e~eo!¢!peo e eJojeq B~ep ez,qeuB Jo
sUO!loedsu! lonpuoo lOU op SHHQ ~o see,~oldUJq 'slueuJeJ!nbeJ el~s pu~ le~epe~ u!e~Jeo,~IS!leS o~ ~ep¢o u! suo!lnl!lSU!
8u!puel qe~p, pu~ se~uoq to s~eseq~nd ol/,SalJnoo ~ se s!ql seop 9HHG e~.L 'e~S~l¥ lo ele~S e~ll u!
Jeeu~§ue leUO!Sse~oJd luepuedepu! u~,~q e^oq~ ~ qde~5~d u! ue^!8 suo!lelueseJde~ et~ uodn/~lUO pes~q
le^o,~dd¥ ,~}pOLIln¥ LI~I~eH s@nss! (SHHa) seo!^JeS uBuJnH pue qlleeH to lueu~l~ede(] eBeJO~lOU¥ ~o ~l!led!o!u nlAI eli&
leUO!]!puoo
//! . ,
le^oJddv I~uoR!puoO ~.o s~JJe/
p@AoJddes!O ~ peAoldd¥
/~q ~LUOOJp~q ~ Jo~. peAoJddv
~VAO~ddV SHHa '9
IBeS s,Jeeu!Su~
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4'/44
Legal Description:
A. WELL DATA
Well Classification _
Well Log Present (Y/N) __ Y Date Completed
Total Depth~__~)
Static Water Level ~' '¢ '
Casing Height Above Ground '8 ¥ '¢
Electrical Wiring in Conduit (Y/N)
SFPARATION DISTANCES FROM WELL:
Cased to ¢--z,~ Depth of Grouting
Pump Set At (,(,~f;o~,,~
Sanitary Seal on Casing (Y/N)
~' Depression Around Wellhead (Y/N) fV
If A, B, C, D.E.C. Approved (Y/N)
Yield ~ ¢ ~,2*r~ ,,~,~
To Septic/Holding Tank orl Lot t'/,/¢. ( ?~xbl~c ~'e~,e~,_~ ; On Adjoining Lots '~' ~(-'~"
To Nearest Edge of Absorption Field on Lot N, A. ; On Adjoining Lots
To Nearest Public Sewer Line '~' ~' __ To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ~ :3'o'
Water Sample Collected by 7T F~ /~o~r¢ ; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed Size
Standpipes (Y/N)
Depression over 'Tank (Y/N)
No. of Compartments
Air-tight Caps Foundation Cleanout (Y/N)
Date Last Pumped
Pumping/M intenance Contact on File (Y/N) ; for
Holding Tank High-Water Alarm (WN) Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well To Building Foundation
To Property Line To Disposal Field
To Water M in/Service Line
To Stream, Pond, Lake or Major Drainage Course
72-026 (ney 7/~]~) Fronl Page 1 of 2
C. ABSORPTION FIELD DATA ^h~,
Soils Rating in Absorption Strata
Date Installed
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
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
Date Installed
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 Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed ¢~'~¢~'~---
Company F l¢lf~ lo,
Date I / / t /
MOA NO. ~;~- O&'-~.
Receipt No. (~
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Waive~ Fee: $
Date of Payment
Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPAt{I~ENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICatION FOR HEALTH AUTHORITY APPROVAl, CE~£IFICATE
1. General Information Application Date June 19, 1984
(a) Legal Description (include lot, block, subdivision, section, t~nship, range)
Lot ]5, B'Iock 8, Sk~wa~ Park Estates, Anch0ra~[e_ Rec0rd~n~ D~str~ct
Location (add,.ess or directions) ]700 Shore Dr~ve
(b) Applicants Na,re Michael B. & S~dse] B. BePgma,, Tslephos~3_4j-9]50
Applicants Address ]700 Shore Dr~ve, Anch0rage, Ak. 995]5
(c) Applicant is (eh~ 0~) ~nding I. nstitution ~--d; ~r~uil~r ~,
(d) ~ndi~ Institution A]aska USA Federal Credit Un,on ~lepho~ 786-2793
Ad.ess 4000 C~ed'it Un,on P~ve, Anchorage, Ak, 99503
(e) Real Estate Coo & Agent ____~/a
Address
Telephone
2. T_k~2e__9_o f_I~ side n cs
Single-Family
N~m~be~ of ~edrooms
3. Wate~ Su~)l_y_
Multi-Family
3
Othezr (~scri~)
Note: If ~nity %~11 system, ~st have w~itten confirmation from the State
~pa~,t~nt of ~viron]~nta]. Conservation attesting to t~ legality and status.
Is ~e ~11 adequate fo~ the n~r of ~s s~cified in this [.~ (Y~)
Onsite L~ ~blic ~ ~nity F-it Holding Tank [i2
Is t~ wastewater dis~sal sys~m a~quate f~ ~e ~er Of ~dro~ .(Y~
[Page 1 of 2]
2--15-84
5._Eng~ neerin. _ ~ Firm P~-ovidin~_~s_~ctions,_ ----_---_Tests, Data and Information
%
I certify that I have checked, verified, or conformed to al.]. MOA ~.AA Guidelines in
effect on the date of this inspection.
Signed ~,'% ~?.~-" ~7: 4. ,~.~-- ..... June 22, 1984
Name of Fi~m quadra Engineering
Add~ess 401 East Fireweed Lane
Date
Telephone_
276-3770
(.ENGINEER SEAL)
Appro~d ~ Disapp~_ oved r~
Terms of C~nditional App,'oval
The Municipality of Anchorage Depa~tra~nt of [-~alth and Enviror~ntal P~otection dc~s
not guarantee the continued satisfactory ~e]:for]r~nce of the water! supply and/or the
wastewater disposal system. ~l]%is approval indicates that, as of the validation date
shcwn abo~, based on the.. data and informatiou furnished by an engineer registered ~n
the State of Alaska, the water supply a~d wastewate~ disposal system is safe and fun¢~
tional for the numbe~ of kedrocms a~d type of struct~uce indicated.
(D~EP SEAL)
7. Mail the }~%A to the following address:
Call owner-builder for__p, iic~k~z_' M_]ichael or'
__~._iid_sel ~mr. Lq_~a__na; 34~rg.15Q3~3].,9.:~j,_~g_276-2761
KB2/d5/s
[Page 2 of 2]
2'-15-84
A. WELL DATA
M[~ICIPALITY OF ANCHORAGE (MOA)
H[,IAL~{ AUTHORITY APP]~OVAL (HAA)
CHECKLIST- FI,~RUARY 1984
Legal Description:
Cased to
Well Classification
Well Log. P~esent (Y/N)
Total Depth &~g'
Static Water Level Wf'
Casing }bight Above Ground
NOI.[D]IO~d -IVJ NaF~NO~i^N,q
'g I'll]V311 Jo 'ldJq
aO¥~OH3N¥ 'JO £tllYdlOINfl~
LOt ]5~ B]~k_8~ Skyway
Electrical Wirinu in Conduit _(.Y/N)
Park Estates, Anchorage, Ak.
Sep~ation Distances f~,om Well:
. ' -- I'q.~
TO ~ptie~olding Ta~ ~ ~t~.~ .~ ~U' ~]joining Lots
To ~a~st ~ of ~so~tion Field on Lot [~ .; ~ Adjoining ~ts
To Nearest Public Sewe~ Line /~d"
Clean t/ oZe/zo'
Wate~ S~le Colle~ed By
Wate~ S~le Test ~sults ~'~C~
To Nearest Public Sewer
To Nearest Sewer F~vice Line on Lot
Cf ailments
B. SEPTIC/HOLDING TANK DATA not applicable
Date Installed Size No. of C~38~tn~nts
Standpipes (Y/N) Ai~-tight Caps (Y/N) _ Foundation Cleanout (Y/N!
Depression ove~ Ta~ (Y/N) Date Last Pumped
Pumping/Maintenance Cont~a~t on File (Y/N) ; fo~
Holding Tank High-Water Alarm (Y/N) Temporary Holding_Tank Permit _(Y/N)
Sep<m~ation Distances f~om Septic/Holding Tank:
To Water-Supply Well
To R~ope~ty Line
.To Water Main/Se~vLce Line
To Building Foundation
To Disposal Field
To' Stream, Pond, Lake, c~ Majo~ D~ainage
Com~nts
C. ABSORPTION FIELD DATA not applicable
Soils ~ating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption A~ea
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes P~esent (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To P~operty Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank(if present
To Stream/Pond/Lake/o~ Major D~ainage Course
To D~iveway, Pa~king A~ea, o~ Vehicle Stc~age A~ea
Counts
D. LIFT STATION
Date Installed
Size in Gallons
"Pu~p 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 du~ing Adequacy Test.
Meets MOA
Co~ents
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection. · _~_:~%~~.Ur "C~ ·
signed r oate
KB1/d5/s E~'" ' .....' .................... .m' ~. '
~¢~ ~ %Michael E. Ar~derson :
[Pa~ 2 of 2]
2-15-84