HomeMy WebLinkAboutSKYWAY PARK ESTATES BLK 8 LT 16
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· OTHER
FINANCED THROUGH
TO BE INSTALLED BY
SOIL TEST RESUL'rS
NOTE= THIS PERMIT IS NOT VALID WITHOUT BOIL TE~,'I'
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL SE SUBJECT TO FROSEEUTION.
SEEPAGE AREA SIZE
, DRAIN FIELD
., DRA]N FIELD
,SEEPAGE PIT
ALSO CONSIDER AREA WELLS.
, SEEPAGE PIT
., ~)RAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
'1
~ ~11
GREENWOOD LANE
DRIVE
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
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 F~r'¢
Mailing Address /
(c) Lending Institution ~¢0~[
Mailing Address
(d) Real Estate Company and Agent
Address ~0~
Telephone
Telephone: Home ~ t~t/'9'CPY Business
(e)
Mail the HAA to the followine address: or: Check here [], if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family []
Number of Bedrooms
6
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If corn m unity 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 from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 fRev 8/881 Fronl
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WELL DATA
MDNICIPALrrY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
MUNICIPALITY OF ANOarapaho:
'~;'I~EI~KLIST - FEBRUARY 1984
ENVIRONMENTAL SERVICES DIVISION 264-4744
Legal Description: _/-,¢'/" I~"',~
RECEIVED
13 Io-cl, c 0
Well Classification Fr"'f U¢'¢'6 If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) ~ Y _ Date Completed I~ -! 7 Yield
Total Depth ,~6 ~ Cased to
Static Water Level ~ 8~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
[~' ~
_ Depth of Grouting /~r/~,
Pump Set At ~ ~'¢ ¢
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
N
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~ (O ~ r
Cleanout/Manhole !
Water Sample Collected by
Water Sample Test Results
Comments /..X/C. ( ( ~E,/'o c<P
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ;> '8.,.¢ '
SI"PTIC/HOI_DING TANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Size _____ No. of Compartments
Air-tight Caps (Y/N) Foundation Cleanout (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Ta,~qk High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Propedy Line
To Water Main/Service Line
Course
Date Last Pumped
; for
Temporary ktolding Tank Permit (Y/N)
To Building FouRdation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72~026 fRev 8/861 Front
C. ABSORPTION FIELD DATA ~'/, (J .
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 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Date
MOA No.
Signed ~~
Company F ~¢/'~p
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72 026 fRev 8/861 8ack
Engineer's Seal