HomeMy WebLinkAboutOLSON HEIGHTS BLK 2 LT 4Olson Heights
Block 2
Lot 4
#018-231-14
Jul 15 22 08:29p Anchorage Well & Pump Ser
9072430742 p.1
MUNICIPALITY OF ANCHORAGE
Development Services DepartmentPhone: 907-343-7904
On -Site Water & Wastewater Section ` Pax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: Date of Issue: _
Parcel Identification Number: 018 231 14
Legal Description Block Lot Property Owner Name & Address:
WESTPHALL PATRICK W & JEWEL M
OLSON HEIGHTS 2 4 4350 E 135TH AVENUE
ANCHORAGE, AK 99516
Pump Installation Date: 07 _ 05 - 2022
Pump Intake Depth Below Top of Well Casing:
Pump Manufacturer's Name: MYERS
Pump Model: 3N FL52-8-P4-02
Pump Size: .50 hp
Pitless Adapter Burial Depth: 14
I Pitless Adapter Manufacturer's Name:
I Pitless Adapter Installer:
Well Disinfected Upon Completion?
Method of Disinfection: PELLETS
I Comments:
60 feet
feet
MARTINSON
Yes ❑ No
Pump Installer Name: _ ANCHORAGE WELL & PUMP SERVICE
7640 KING STREET
Company: ANCHORAGE, AK 99518
907-243-0740
Mailing Address:
City
State: Zip:
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
Inspection Report—f-1-12.doc
Municipality of Anchorage
Community Development Department Page 1 of 3
On-Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904
ON-SITE
WASTEWATER INSPECTION REPORT
Permit Number: OSP141322
PID Number: 018-231-14 ❑ New ❑✓ Upgrade
Name:
Patrick & Jewel Westphal]
ABSORPTION FIELD
❑✓ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
4350 E. 135th Avenue
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
0.45 GPDISF
13.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3,0 Ft.
Gravel depth beneath pipe
10.0 Ft.
Subdivision
Block Lot
Olson Heights
2 4
Fill added above original grade
0.5 Ft.
I Gravel length
70.0 Ft.
Township Range Section
Gravel width
2.5Ft.
Beds: Number of Lines
N/A
Distance between lines
N/A Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Lift Station
Tank
Line
1,400 Ft
2
20.0 Ft.
Well
133.6
153.4
N/A
N/A
129.6
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Anchorage Tank
Capacity
1250Gal.
Surface Water
100+
100+
N/A
N/A
Material -
STEEL
Number of compartments
2
Lot Line
28.69
13.7
N/A
N/A
NA
Foundation
8.4
13.0
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
50+
50+
N/A
N/A
Remarks
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
-
Pump make and model
Electrical Inspections performed by
PIPE MATERIAL House to tank 3034 drainfield Tank to
3034
Installer
A+ Home Services
Drainneld 3034 CO/MT 3034
Inspector Pannone Engineering Services
BENCHMARK (Assumed elevation) 100ft
Inspection1°` 9/1612014
dates:
-
2m 9/17/2014
Location and description
3r0
4th
Bottom of Trim
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
Conditional Approval:
Date
TH
... ...
,Ieveti 'k. *0 , noAe'/f
CE 81
JaAAA.1%
IV41_1
ApprovedDate
I A
!/_'o/k�.�+
Inspection Report—f-1-12.doc
WELL (E)
o �
133.6
'LOT 4
\ w�- w__
i
3BR
HOUSE
(E)
B
SHE
NEW UPGRADE DRAIN FIELD
(2EA) 35LF x 2.5'W x I O.O'ED x 13.0'TD
10' UTILITY EASEMENT
—J I
*IF IN THE FUTURE THE HOUSE IS EXPANDED
TO 4 BEDROOMS, UPGRADE SYSTEM (P) MAY BE
USED AS 4 BEDROOM SYSTEM. EXISTING SYSTEM
TO BE RE -USED AS A RESERVE WILL NEED TO BE
UPGRADED TO ACCOMMODATE A 4 BEDROOM RESERVE.
PANNODNE7 ENHORASVC, 99510 � .��OFA",kk l') D10/3/14
PHONE (907) 272-8218 FAX (907) 272-8211 %q�P �y+r Scale
NOTES:
RECORD DRAWING
PLAN
G
DRAIN FIELD (E)
IN FAILURE
L��o
RE-USE AS RESERVE
ABANDONED 1250g SEPTIC TANK
PER CODE
INSTALLED NEW 125ng SEPTIC TANK
WITH DCO AND DV
i 1 u _DV I i
T2
FLOW SPLITTER
M 1
TH—
S
h° �1 %
M21\3
1_1
ss
,l\ 20.0
VM4
�Q
i- z
_J W
� W
Q
OLSON HEIGHTS, BLOCK 2, LOT 4
PATRICK & JEWEL WESTPHALL
4,350 E. 135TH AVENUE
ANCHORAGE, AK 99516
1.._30'
.... ... .. .. ... P.I.D. NO
018-231-14
Steven Pann6.6 1 PERMIT NO.
I�P CE 8149 .\e`er/ OSP141322
�tl%� OFES`OV Sheet
eOF 3
A
B
FC
8.8
Tt
13.7
19.2
T2
20.4
23.9
DCO
22-9
25.6
DV
26.1
28.3
C 1
32.0
17.0
M1
32.2
16.6
C2
64-4
47.3
M2
64.3
47.4
C3
522
26.2
M3
53.0
27.0
C4
77.3
54-3
M4
1 77.3 1
54.0
WELL (E)
o �
133.6
'LOT 4
\ w�- w__
i
3BR
HOUSE
(E)
B
SHE
NEW UPGRADE DRAIN FIELD
(2EA) 35LF x 2.5'W x I O.O'ED x 13.0'TD
10' UTILITY EASEMENT
—J I
*IF IN THE FUTURE THE HOUSE IS EXPANDED
TO 4 BEDROOMS, UPGRADE SYSTEM (P) MAY BE
USED AS 4 BEDROOM SYSTEM. EXISTING SYSTEM
TO BE RE -USED AS A RESERVE WILL NEED TO BE
UPGRADED TO ACCOMMODATE A 4 BEDROOM RESERVE.
PANNODNE7 ENHORASVC, 99510 � .��OFA",kk l') D10/3/14
PHONE (907) 272-8218 FAX (907) 272-8211 %q�P �y+r Scale
NOTES:
RECORD DRAWING
PLAN
G
DRAIN FIELD (E)
IN FAILURE
L��o
RE-USE AS RESERVE
ABANDONED 1250g SEPTIC TANK
PER CODE
INSTALLED NEW 125ng SEPTIC TANK
WITH DCO AND DV
i 1 u _DV I i
T2
FLOW SPLITTER
M 1
TH—
S
h° �1 %
M21\3
1_1
ss
,l\ 20.0
VM4
�Q
i- z
_J W
� W
Q
OLSON HEIGHTS, BLOCK 2, LOT 4
PATRICK & JEWEL WESTPHALL
4,350 E. 135TH AVENUE
ANCHORAGE, AK 99516
1.._30'
.... ... .. .. ... P.I.D. NO
018-231-14
Steven Pann6.6 1 PERMIT NO.
I�P CE 8149 .\e`er/ OSP141322
�tl%� OFES`OV Sheet
eOF 3
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION WAS INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE
STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON—SITE
WASTEWATER DISPOSAL SYSTEMS AND ATTACHED SPECIAL PROVISIONS.
2. SCOPE OF WORK: INSTALLED NEW 1250g SEPTIC TANK WITH DCO, DV, AND FS, AND SOIL ABSORPTION SYSTEM.
3. GROUNDWATER WAS NOT ENCOUNTERED TO 19 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL TEST HOLE.
AN APPARENT WATER TABLE WAS NOT OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 19 FEET BELOW EXISTING
GRADE.
r FILTER FABRIC
4" 0 PERF PIPE
DRAIN ROCK 6" ABOVE PIPE INV
97 O TH-1
1 -1.0OR-
3.0
-94.0
€` GM
100
DRAIN POCK
L-84.0
6.0
1250g SEPTIC 94.5 _ 'W 7' -94.C'
TANK (N)
r yi
-940
PROFILE r sA
SECTION
Cu COPPER
DESIGN PARAMETERS
>w w
w
PRIMARY SEPTIC SYSTEM
0
ao
m
o.
ao
o'w'ow
A
W WATER LINE/
o z
zQ
za
w mW s zQ ,_
M# MONITOR TUBE NO.
zz
'�'
RIGID w o�>ow
a
w
oa
CINSULATION
USED:
1250g SEPTIC 94.5 _ 'W 7' -94.C'
TANK (N)
r yi
-940
PROFILE r sA
ABBREVIATIONS
Cu COPPER
DESIGN PARAMETERS
TRENCH SEE DESIGN
DIP DUCTILE IRON PIPE
PRIMARY SEPTIC SYSTEM
TH TEST HOLE
NO. BEDROOM: 3 (450 gpd)
LEGEND
FC FOUNDATION CLEAN OUT
TANK SIZE: 1250g
T# TANK CLEAN OUT NO.
PERC RATE: 39 MPI
W WATER LINE/
C'T CLEAN OUT NO.
SOIL RATING: 0.45 GPD/SF
WELL RADIUS
M# MONITOR TUBE NO.
AREA ROD: 1000 SF
R.I. RIGID INSULATION
SYS. TYPE: DEEP TRENCH 10.0'ED
SS — NEW SEPTIC
DCO DOUBLE CLEAN OUT
MIN LENGTH: 50 LF
DV DIVERTER VALVE
USED:
FS FLOW SPLITTER
(2EA) 35 0x10.0' E.D.,
13.0' TG
BFG BELOW FINISH GRADE
TOTAL AREA:A: 1 1,4,400 SF
OG ORIGINAL GRADE
FG FINISH GRADE
TS&V TOPSOIL AND VEGETATE
NOTES:
PANNONE ENG SVC, LLC
_—��� �Vl
�F A�.gsl)✓,
Date
RECORD DRAWING
P.O. BOX 100217 ANCHORAGE, AK 99510
�(y
1/7/14
PHONE (907) 272-8218 FAX (907) 272-8211+
*: '.*I"
...... .... .. ......
Scale
-NTS
P.LD. NO
- 1-14
OLSON HEIGHTS, BLOCK 2, LOT 4
PATRICK &JEWEL WESTPHALL
4,350 E. 135TH AVENUE
/ StPannone n eveR.
r PF.•, CE 8149
f
+,Il`FOpRO
PERMIT No.
OSP141322
DESIGN DETAILS
ANCHORAGE, AK 99516
Sheet
TSSIONP'_
3 OF 3
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP141322
Tax Code Number: 01823114000
Work Type: Septic Upgrade
Permit Effective Dates: August 25, 2014 to August 25, 2015
Design Engineer: PANNONE ENGINEERING SERVICE
Subdivision: OLSON HEIGHTS
Site Legal Address: OLSON HEIGHTS BLK 2 LT 4 G:2936
Owner/Address: WESTPHALL PATRICK W & JEWEL M
4350 E 135TH AVENUE ANCHORAGE AK 995163601
Site Mailing Address: 4350 E 135TH AVE, Anchorage
This permit is for the construction of:
Y Disposal Field Y Septic Tank N Holding Tank
Lot Size in Sq Ft: 49500
Total Bedrooms: 3
N Privy N Private Well N Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By
Issued By:
MUNICIPALITY OF
Community Development Department
Development Services Division
On -Site Water & Wastewater Program
ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 018-231-14
Property owner(s) Patrick & Jewel Westphal) Day phone
Mailing address 4350 E. 135th Avenue, Anchorage, AK 99516
Site address 4350 E. 135th Avenue
Legal description (Sub'd., Block &Lot) & 2,—Eat-2—
Legal
,"`Legal description (Township, Range & Section) GlllSM flci-bKN5 2 L_4
Lot Size 49,500 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑x
Initial ❑
Single Family (SF)
❑x
(w/wo ADU)
Septic Tank
❑x
Upgrade ❑X
Duplex (D)
❑
Holding Tank
❑
Renewal ❑
Multiple Dwellings
❑
Privy
El
(SF and/or D)
Private Well
El
Water Storage
❑
AUG 12 2014
THIS APPLICATION INCLUtL�SA VARIANCE / WpIVE FOR:
GIYEQUEST
(' '
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
property owner or
Permit/Rush Fees: rJ 0
Date of Payment: F1I2411
Receipt Number:. y qq
Permit No. oepl? { 132Z
Permit App_:;- :
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail: stevef@panen¢ak.com
August 8, 2014
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road
P. O. Box 196650
Anchorage, Alaska 99519
Subject: Olson Heights, Block 2, Lot 4
Septic System Upgrade Permit Request
Ladies and Gentlemen:
I am writing to request a permit to install an upgrade septic system be issued for this property. The
proposed systems will serve a existing three (3) bedroom house. Currently the existing field is in failure .
The existing 1250g septic tank will be abandoned per code and a new 12508 septic tank will be installed.
An upgrade deep trench type drain field will be installed and the existing failed field will be re -used as a
reserve. This lot is served by a private well. The surrounding lots are also served by private wells. There
are no wells within 100' of this system.
Soils. Pannone Engineering performed one test hole on this lot in July of 2014, and groundwater was
monitored for seven days. Ground water was not observed below the ground elevation in the test hole
monitor tube. It is my opinion, based on the results of the soils tests and overall soils appearance; an
application rate of 0.45 gallons/day/square feet should be used for a conventional wastewater system.
1. Soil Absorption System Design.
a. See Sheet 2 of the design package.
2. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain
field. The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage
ditches.
3. Topography: The proposed drain field is located on the southeastern portion of the lot. The
surrounding topography generally slopes from northeast to southwest and the area immediately
surrounding the drain field is flat. There are no steep slopes in the vicinity.
Mailing: P.O. Boz 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
Page 2 of 2
4. Drawing Markings: The Drawings are marked "For MoA Review Only'. When written notification
that the review is complete and that there are no further comments is received from MoA On -Site
Department, the note will be removed and "Issued for Construction" drawings will be issued.
The proposed installation will not affect the future development of the surrounding or existing lots.
If you have any questions or concerns, please contact me at 272-8218.
Sincerely,
Steven R. Pannone, P.E.
Owner/Civil Engineer
Mailing: P.O. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor Ave, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
\ EAST 135TH AVENUE
wA�
is
� I 3
WELL (E) -
. � A •I
D j
1 WELL (E)
F
�4N �
132.5
LOT 4
DRAIN FIELD (E)
/\� - IN FAILURE SEPTIC AREA (E)
RE—USE AS RESERVE .••FFF���
w ABANDON 12509 SEPTIC TANK (E)
w PER CODE /
38R INSTALL 12509 SEPTIC TANK (P)�
HOUSE WITH DCO AND DV
_ (E) ` FLOW SPLITTER -
AREA (E) I 1.0.0 10.7
- SHEJu / _ TH-1
UPGRADE DRAIN FIELD' (P)
(2EA) 35LF x 2.5'W x 10.O'ED x 13.0'ED
_ 10' UTILITY EASEMENT
N W � W
--- �� SEPTIC AREA (E)
I
'IF IN THE FUTURE THE HOUSE IS EXPANDED
TO 4 BEDROOMS, UPGRADE SYSTEM (P) MAY BE
USED AS 4 BEDROOM SYSTEM. EXISTING SYSTEM
TO BE RE -USED AS A RESERVE WILL NEED TO BE
UPGRADED TO ACCOMMODATE 4 BEDROOM RESERVE.
NOTES: ate
7��M N i T OF A( `il 08/25/14
FOR CONSTRUCTION rtflrlr01�1-' ENG �C, LLC �'
P.O. BOX 100217 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211 Co. �y+) Scole
..... .. P.LD. NO
OLSON HEIGHTS, BLOCK 2, LOT 4 a1s-z3i-ia
PATRICK & JEWEL WESTPHALL � tevenn agnno.ne� PERMIT NO.
CE 8149
14
OSP141322
4350 E. 135TH AVENUE ti
PLAN ANCHORAGE, AK 9951610... ....S00 Sheet
�� "�� 1 OF 3
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF
ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF
ON–SITE WASTEWATER DISPOSAL SYSTEMS AND ATTACHED SPECIAL PROVISIONS.
2. SCOPE OF WORK: INSTALL NEW 1250g SEPTIC TANK WITH DCO, DV, AND FS, AND SOIL ABSORPTION SYSTEM.
3. GROUNDWATER WAS NOT ENCOUNTERED TO 19 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL TEST HOLE. IF
AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 19 FEET BELOW EXISTING GRADE
.NOTIFY THE ENGINEER IMMEDIATELY.
FILTER FABRIC
4' 0 PERE PIPE
ROCK 6' ABOVE PIPE INV
TH-1
-1.0 OR
3.0
L
GM
10.0
DRAIN ROCK
1
6.0
I SECTION
12509 SEPTIC
TANK (P)
PROFILE
DESIGN PARAMETERS
PRIMARY SEPTIC SYSTEM
NO. BEDROOM: 3 (450 gpd)
TANK SIZE: 1250g
PERC RATE: 39 MPI -
SOIL RATING: 0.45 GPD/SF
AREA ROD: 1000 SF
SYS. TYPE: DEEP TRENCH 10.0'ED
MIN LENGTH: 50 LF
USE:
(2EA) 35 LFx2.5'Wx10.O' E.D., 13.0' TO
TOTAL AREA: 1,400 SF
LEGEND
W WATER LINE/
WELL RADIUS
SS — NEW SEPTIC
ABBREVIATIONS
CU
COPPER
w
DUCTILE IRON PIPE
TH
TEST HOLE
m
m
T#
TANK CLEAN OUT NO.
C#
CLEAN OUT NO.
Oj
7
O
J Jp J
O WO w m0 O
�
O O
<O
Cza
.DOUBLE CLEAN OUT
i
SOILS LOG - PERCOLATION TEST
DATE
CLOCK
TIME
TEST HOLE 1
WATER
LEVEL
READING
NET DROP
OR ORGANICS SLOPE
SITE P A
3:00
\
W
6.19
---
2 W—_ W
3:30
3 3FIR
6.96
0.77
HOUSE
—
3:30
_ E
6.19
---
5
4:00
6 X
6.95
0.76
TH
4:00
7
6.19
---
$ SHEu /
TH-1
4:30
9
6.95
0.76
GM SILTY GRAVEL
10 GRAY/BROWN
LI
Z z
11 10' UTILITY EASEMENT
12
- 'nw 'nw
13
WAS GROUND WATER
SLOPE
14 ENCOUNTERED? N
15 IF YES, AT WHAT -
TH
DEPTH? ---
X
16
17 DEPTH TO WATER AFTER
MONITORING? -DRY-
18 DATE: 616/14
19
BOH
DATE PERFORMED: 7/31/14
PEROLATION RATE _ 39 (min/inch) PERC HOLE DIAMETER 6 inches
TEST RUN BETWEEN 4 FT AND
5 FT
COMMENTS: Test hole excavated by A+ HOME SERVICES. Prec hole was presoaked.
Test run for at least one hour. Last 3 readings reported
PERFORMED BY: Steven R. Pannone, P.E. I CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST.
NOTES:
PP.o. eo �ioa EINC
_��� \k
OF A`'gsl�1
Date
S/25/14
FOR CONSTRUCTION
ORACK 995rIo
�y+0
scale
PHONE (907) 272-8218 FAX (907) 272-8211
iaj�p
*: .*. �/
..... ... ....
NTS
P.I.D. NO
OLSON HEIGHTS, BLOCK 2, LOT 4
/
018-231-14
PATRICK & JEWEL WESTPHALL
-4350 E. 135TH AVENUE
Steven R. Pannone %
Pc, CE 8149 .'e��
f .•fir
t�liR�OSONP=G
PERMIT NO.
OSP141322
Sheet
SOILS LOG
ANCHORAGE, AK 99516
READING
DATE
CLOCK
TIME
NET TIME
WATER
LEVEL
READING
NET DROP
1
7/31114
3:00
---
6.19
---
z
3:30
30 MIN
6.96
0.77
s
3:30
--
6.19
---
a
4:00
30 MIN
6.95
0.76
s
4:00
---
6.19
---
s
4:30
30 MIN
6.95
0.76
MUNICIPALITY OF ANCHORAGE
® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 LStreet -Anchorage, Alaska 99501 Telephone 264-472.0
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPO/RC{T�
NAME PHOT—I-� KNEW
n ,�jo-
51 �Q� ( ❑UPGRADE
MAILING ADDRESS //-
a.
LEGAL DESCRIPTION
LOCATION j� /)
.�
N0. OF BEDROOMS
v
DISTANCE TO:
Well
� � /')
Absorption area
� I
Dwelling
1 2— 1
PERMI O ��
h
Material
Tec
No. of compart ents
Manufacturer/
w
J)
w
Liq. f,7 jU' gallons
r�G( d
IF HOMEMADE:
Inside length
Width
Liquid depth
X
DISTANCE TO:
Well
Dwelling 0
PERMIT NO.
8 Z F
Manufacturer
Material
Liquid capacity in gallons
w T
DISTANCHTO:
WellFoundation
Nearest lot ine
PERMIT NO.
j. z W
No. of linesLength
ofgaSLh_linp
Total I �n t of lines
Trench. w�tly
inches
Distance between lines
I—
O
Top of the to finish grade r�,
� r
Material beneath tile
- inches
Total effective bsorption area
��
Length
Width
Depth
PERMIT
w
U'
Q f-
Type of crib
—
Crib diameter
Crib depth
Total effective absorption area
a E:
w
_
DISTANCE T0:
Well
Building foundation
Nearest lot line
a
Class
Depth
Driller
Distance to lot lineJ
RMIT NO.
�
�
wDISTANCE
T0:
Building foundation
Sewer line
Septic tank
sorption area(s)
OTHER
PIP,�MATF�iIALS/J
—
SOI L TEST`RAJT_I�NG
V TI
INSTALLER
REMARKS
1
°
r
)LEGAL
` G—�V
r
F
A ROVED DATE 6112— /
C� 4
»n1v lo.... oiloi
WeiI Log
F'or.........��I�..... �/t i�2. 0
Vocation.....®.......�....C� ..... 9�C0� �1���/�.,.,..E�,
�
Date completed........ ....7....
Depthof well........ �.. o........................................................................................
Sizeof casing .................... -...... ............ ............................ .......................................
Distanceto water.................................................................................:�.....,.........
Distance to water while pumping.................�S. Z................................at rate
of ............... 4. ....................gallons per hour.
Formation.
F from
( to
CCAY, G&A v64-
694 U6'6"' (�61y 040(54421
(
( I
/- X&OP4ko)
14!
149
.54VOY f_U_�y'_
aioU G� �o �fo L396 6:s
1:58
1 6Z-' .4.11
.............................................
Driller
DELTA DRILLING COMPANY
SRA BOX 394 B
ANCHORAGE, ALASKA 99507
THE REQUIRED '_:J.ZF�//J 1__1F/'_ ' i�. �a.`,131L ABSORPTION 'C"T" T[ y .T.` n q C � y _
11..•fl IF" ®.....� II_ 0•.,, H'_"'` ...gym'•"_.. ®-NI a....� �- fl- tl ..".__ ® ° °fli ° L_ r,*- IE.7 If � -T u..., ° e.
THE LENGTH DIMENSION I S 'THE LENGTH �I to FEET) OF 'THE TRENCH OR G RA I NF I ELD.
THE DEPTH OF A TRENCH OR P I T IS THE DISTANCE CE= BETWEEN THE -SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION �11`4 FEET).
THERE. IS NO .E'T' WIDTH FOR TF:EI`-JCHES.
THE GRAVEL. [::DEPTH IS THE MIh INLIN DEPTH OF' GI=.AVEL BETWEEN THE: OUTFALL. F'IF'E
I if -4D THE BO"I"TOM OF THE E'XCAVAT I ON f'. I N FEET).
If ' �� a a M. II : 6 ' ? "-=� IF if �: c. =1 A°. 9 6 • T 'L "F'= —,. g_ NZ-) C. -I M=;u C -,u IF=S R....... L._. Co PA
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT D1JF.,..TNG THE
I NSTALLAT I Ot•d INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESII::,E'N ES THAT THE WELL 14ILL SERVE.
....... _.._....._. _r W a_.a °". 2T. -I > I�-� °:� �"'" �': a-�: �_" I a_a �'-a 6" � F' FE— IFS-' IF- CA IIJ I Fe L E" n ...__ ..._-- _.......
BACKFILLING OF ANY LL SYSTEM Fd:[ T'Hi �I..IT' FINAL I t� F'EC:T I Otd AND AF'PF:� i+;'r=iL B31.
r'
THIS
DEPARTMENT WILL. BE SLIBJ'EC-:T To PROSECUTION.
MIt•-IIC'UM DI:=:TANf.E E:E:TkIEEN A LIELL. AND ANY ON-SITE rSEWAGE: DISPOSAL _31TIS'TEN I'S
1.00 FEET FOR A PRI %*]TE WELL. OR 150 TO 200 FEET FROM A F'UBL_ I[ .:: WELL DEPEND I NJ."?
IJPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL. TO A PRIVATE 'SEWER L. I NE: I �_-, u:5 FEET AND
TO A COMMUNITY '-EWER LINE IS 75 FEET,
WELL.. LOG.- FIRE REQUIRED FIND MUST BE RETURNED TO THE DEPARTMENT WITHIN 2:0 DA',•":
[.IF 'THE WELL COMPLETION.
OTHER REQUIRElIENTS MAY APPLY. SPE.CIFICATIOt'S AND i..ON.1 TRUCT.IOI%d
FiV A I LAELE TO INSURE PROPER INSTALLATION.
r„ F=7 r;;. rn� �. -.�... IFS :- IF• IFs E:. a = r• I-* E: F-". f I... J_ I- -oac:�a
THAT
1.: I: All FAMILIAR I.d I "I H 'THE f :EG!U I REMENTE FOR i N.•-� .T. Tr' SEL IER:= f"it• D WEI._I.. FI:; SIE" T'
FORTH BY THE MUNICIPALITY OF' ANCHORAGE.
I WILL. INSTALL THE SYSTEM I? -,I ACCORDANCE WITH THE CODES.
I I.JNDER'_:3TAND THAT THE ON --SITE SEWER ' 4's"fE C I MAY RU U I RE ENLARGEMENT IF THE
RESIDENCE IS IT;EMODE'L..ED To INCLUDE MORE THAtd BEDROOMS.
I GNU
F I�PT 9DU ! ZZ 1. 1
:f.:_.,UED
rq �.._' M"-� I a-_- �'' �."`A IL._._ ...
°�. ° 0 -Di IF7 FA r-4 B,':: ^...A a. _a F" F`• -fl IC3
I I , 16
DEPARTMENT OF HELL_TF•I
AND ENVIRONMENTAL PROTECTION
�•��'J _F � .. wb
825 'L' STREET,
ANCHORAGE, AK. 995VJ-_I_
64--4720
V .
W F_ L_... I<_. F•=! Ir --J U,"m
"IF F-7 7 -EF E=- U 4 E:_ F_eIF'�' P T F-'11-1
1'. 'T'
PERMIT
NO. c 800k_'197 i
APF'L.IC:At•a-f
ED HERZOG
P. 0. 1.,0 a.-,- 7
`;;44--9977.
LOnCFITION
135TH Fi%,'E.
LEGAL
LOT -4 BLK 2 OLSEN HT`.-.=,1_IE:
LOT SIZE 50000 FEET
TYPE. OF
SOIL ABSORPTION SYSTEM :['S : TF::Et•
CH
MAXIMUM
NUMBER OF BEDROOMS = _
OIL RATING ( S(7i F: T'.:'E:F "j --
THE REQUIRED '_:J.ZF�//J 1__1F/'_ ' i�. �a.`,131L ABSORPTION 'C"T" T[ y .T.` n q C � y _
11..•fl IF" ®.....� II_ 0•.,, H'_"'` ...gym'•"_.. ®-NI a....� �- fl- tl ..".__ ® ° °fli ° L_ r,*- IE.7 If � -T u..., ° e.
THE LENGTH DIMENSION I S 'THE LENGTH �I to FEET) OF 'THE TRENCH OR G RA I NF I ELD.
THE DEPTH OF A TRENCH OR P I T IS THE DISTANCE CE= BETWEEN THE -SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION �11`4 FEET).
THERE. IS NO .E'T' WIDTH FOR TF:EI`-JCHES.
THE GRAVEL. [::DEPTH IS THE MIh INLIN DEPTH OF' GI=.AVEL BETWEEN THE: OUTFALL. F'IF'E
I if -4D THE BO"I"TOM OF THE E'XCAVAT I ON f'. I N FEET).
If ' �� a a M. II : 6 ' ? "-=� IF if �: c. =1 A°. 9 6 • T 'L "F'= —,. g_ NZ-) C. -I M=;u C -,u IF=S R....... L._. Co PA
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT D1JF.,..TNG THE
I NSTALLAT I Ot•d INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESII::,E'N ES THAT THE WELL 14ILL SERVE.
....... _.._....._. _r W a_.a °". 2T. -I > I�-� °:� �"'" �': a-�: �_" I a_a �'-a 6" � F' FE— IFS-' IF- CA IIJ I Fe L E" n ...__ ..._-- _.......
BACKFILLING OF ANY LL SYSTEM Fd:[ T'Hi �I..IT' FINAL I t� F'EC:T I Otd AND AF'PF:� i+;'r=iL B31.
r'
THIS
DEPARTMENT WILL. BE SLIBJ'EC-:T To PROSECUTION.
MIt•-IIC'UM DI:=:TANf.E E:E:TkIEEN A LIELL. AND ANY ON-SITE rSEWAGE: DISPOSAL _31TIS'TEN I'S
1.00 FEET FOR A PRI %*]TE WELL. OR 150 TO 200 FEET FROM A F'UBL_ I[ .:: WELL DEPEND I NJ."?
IJPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL. TO A PRIVATE 'SEWER L. I NE: I �_-, u:5 FEET AND
TO A COMMUNITY '-EWER LINE IS 75 FEET,
WELL.. LOG.- FIRE REQUIRED FIND MUST BE RETURNED TO THE DEPARTMENT WITHIN 2:0 DA',•":
[.IF 'THE WELL COMPLETION.
OTHER REQUIRElIENTS MAY APPLY. SPE.CIFICATIOt'S AND i..ON.1 TRUCT.IOI%d
FiV A I LAELE TO INSURE PROPER INSTALLATION.
r„ F=7 r;;. rn� �. -.�... IFS :- IF• IFs E:. a = r• I-* E: F-". f I... J_ I- -oac:�a
THAT
1.: I: All FAMILIAR I.d I "I H 'THE f :EG!U I REMENTE FOR i N.•-� .T. Tr' SEL IER:= f"it• D WEI._I.. FI:; SIE" T'
FORTH BY THE MUNICIPALITY OF' ANCHORAGE.
I WILL. INSTALL THE SYSTEM I? -,I ACCORDANCE WITH THE CODES.
I I.JNDER'_:3TAND THAT THE ON --SITE SEWER ' 4's"fE C I MAY RU U I RE ENLARGEMENT IF THE
RESIDENCE IS IT;EMODE'L..ED To INCLUDE MORE THAtd BEDROOMS.
I GNU
F I�PT 9DU ! ZZ 1. 1
:f.:_.,UED
❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE
c DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ER"*�'PERCOLATION
Pouch 6$50, Anchorepe, Alaska 99502 276.2221 TEST
SOILS LOG — PERCOLATION TEST
PERFORMED FOR:
D H -27 o `1/47-.s,DATE
Gross
Time
PERFORMED: A/ 1e/ C .•
LEGAL DESCRIPTION:,
4- �� I �eAj
DEPTH
(FEET)
(� -- Y`�rel
SLOPE
SITE PLAN
}�h
2
Z SU nc�� S i
I
Ezra
�sy
30,„
3
+ I
I
;
5
i?R P" 14 `a 1--
Z / (e -D'e- yl S rL
j
__.
IE!
13
14
15
16
17
18
19
20
COMMENTS Z J-0
WAS GROUNDWATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
�S L
L
O
P
_ E
S
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
Ezra
�sy
30,„
PERCOLATION RATE
TEST RUN BETWEEN
0 -(minutes/inch)
.d r
FT AND.> 1 0 FT
PERFORMED BY: L_ ell S flu C� �� � CERTIFIED B
72-008 (7/76)
DATE: �L ZO // L)
Q,-�SOILS LOG
MUNICIPALITY Or ANCHORAGE
a DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
-- �
Pouch 6660, Anchorage, Fdaske 99502 2762221 TEST
SOILS LOG
- PERCOLATION TEST c
PERFORMED FOR: ! - �� Z l i �� DATE PERFORMED:^ -" F0
LEGAL DESCRIPTION:.
DEPTH SLOPE _ _-- SIT I-' NJ
r -r j T - �—
L L
may
(FEET) D., , /') (S i
J �
1-4
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
PERFORMED
72009 (7/76)
V, N - -
i
i
WAS GROUNDWATER �I U 5
-- ENCOUNTERED? L w
---- 0
P
E
IF YES, AT WHAT
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
Cl
// TEST BEl[PEEN � FT AND
Z�7 6✓J LD _CERTIFIEDBy. _' ,
(minutes/inch)
__. FT
DATE:__1�
i
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OP HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION POR ITUAL,In AUTHORITY APPROVAI. CIsRTIFLCAlE 1
1. General Information Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
i -e 9 q. niir 4 f�wz � -i' !a. !fab --3 ��ac :L J 1 I �1 j(' r t'
Location (address or directions)
(b) Applicants Name A D Business �TT
Applicants Address ���e B
(c) Applicant is (check one) Lending Institution , Ouner/builder ;
Buyer ; Other (explain);
(d) Lending Institution41 a�p Telephone_.°
Address
(e) Real Estate Co. & Agentl�y��1�Lu - ? j
Address
Telephone _ ;j --
(f)
(f) Mail the HAA to the following address:
20 ape of Residence
Single -Family � Multi -Family
Number of Bedrooms
3, Nater Suppl
Individual Well Community E:�l
Other (describe
Public [=[
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite Public Community �`� Holding Tank
:Vote: 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.]
lu
5. Enpineexin� Firm Providing Inspe(Liions, Testr,P rile 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 ghat,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site crater supply and/or wastewater disposal
system is in compliance filth all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this in"detion.
Name of Firm f,{ 4s(..{
Telephone
Address
Date�� ` t� lL®�
b ��_�
C�
(ENGINEER SEAL)
�=Ir
6. DHEP Approval
e`DY a p'o
Gt°o�os , Q. l2?5 a
JUNE 26, d97I,
,C) °
%
Approved for�.ce
bedrooms By �_,
Wa�t^^°at
Approved ��\ P
Disapproved
Conditional '~
Terms of Conditional
Approval
1414111*j1$11
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED REPRESENT—
UPON TRE REPRESENT
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCIlASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. 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 E'NGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D13
[Page 2 of 2] 7-19-34
MUNICIPALI`IY OF ANaIORAOE
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MOA)ENVIRONMENTAL PROTECHOM
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1994 APR 2 9 lloa!-)
264-4720
Legal Description: 40 /-/ MEIV Wselv N71,
r/ 2 N fc :3 t,-, Scz c a -2
A. WELL DATA
Well Classification V" f If A, B, CC, D.E.C. Approved (Y/N) Al
Well Log Present (Y/N) _---/-VDate Completed Yield _ 6 ,4% •
Total Depth Cased to 6 "2 Depth of Grouting
Static Water Level i Pump Set At
"r
Casing Height Above Ground /off Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) a1w y Depression Around Wellhead (Y/N)
Separation Distances from Well:
f� t
To Septic/Holding Tank on Lot On Adjoining Lots
To Nearest Edge of Absorption Field on Lot /420 �s ; On Adjoining Lots
To Nearest Public Sewer Line *C To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line
JJon�Lot �S
Water Sample Collected by Date 3;/o-J—
Water Sample Test Results Sc; 7'-`'
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed J;�ij_0 Size �`� 5_0 No. of Compartments _ 1_�:Z`
Standpipes (Y/N) - / Y—Ar-tight Caps (Y/N) —./ J/ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) - %V ---Date Last Pumped
Pumping/Maintenance Contract on File (Y/N)'"/`Z _ ; for
Holding Tank High -Water Alarm (Y/N) A Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well /Gca '�-
To Property Line / ""
To Water Main/Service Line
Course"—
Comments
Page 1 of 2
r
To Building Foundation _
To Disposal Field __ 7 "
To Stream, Pond, Lake, or Major Drainage
t4%-,oU
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata XS
0 Type of System Design
Date Installed Length of Field
Width of Field Depth of Field 7
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Gravel Bed Thickness
f '1
le"n c 71-0 �
,6_/
— Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well Q6)`') To Property Line �D
i
To Building Foundation X25 To Existing or Abandoned System on
Lot IL)Di,t-- ; On Adjoining Lots 3o
To Water Main/Service Line lUTo Cutbank (if present) 44r,�'%C
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
** Check Permitted Bedroom Rating Against HAA Request **
Vent(Y/N)
Pumping Cycles during Adequacy Test, Meets MOA
I certify that I have checked, verifiO or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed + Date 2 ��
Company MOA No. e- -S
Receipt No.
Date of Payment°' ° ° t.:'�?l9
�.•°° L
Amount: $ er's.`�e1,
�.. •��•- endo° a •. o ••�
�a �• F• •••• moi•• eye �'
Page 2 of 2 JV NE 25, 1971 ,'av
72-026 nvaa °� �(-)P+f€`.1T,
203 W. 15th
E 203
U O° ° C�i A 8 V ULI LIU L�iA N DL7 l� Q E Q ANCHORAGE, V ALASKA IT99501
CONSULTING ENGINEER TELEPHONE: (907) 2793916
Barbara Taylor
Jack White Realty
Anchorage, Alaska
WELL AND SEPTIC SYSTEM ADEQUACY TEST
LEGAL: Lot 4, Block 2, Olsen Heights Subdivision
LOCATION: Anchorage
RESIDENCE: Single Family, Three Bedroom
WATER SYSTEM: On site well test pumped at 7 GPM for 4 hours
Well has potential of 7 GPM flow rate
SEPTIC SYSTEM: From Municipal Records:
Tank: 1250 gallons
Absorption System: Trench, 45 feet long,
7 feet deep, 5 feet of sewer rock
Absorption Area: 450 square feet
Original Soil Rating: 150
Installation Date: 1980
DATE OF TEST: April 23, 1985
TEST PROCEDURE: Drainfield was charged with water at a steady
flow of 7 GPM. A total of 480 gallons of water was added to the
trench over a 3 hour period. Both the septic tank and the sump of
the drainfield was monitored. The water level in the tank did not
change during the test. The water level in the sump was measured
at 91" below the top of the sump at the beginning of test and 71"
below the top of the sump after addition of fresh water. Sump
recovery readings indicate acceptance of water. The tank was
pumped on April 25, 1985.
TEST RESULTS: Both well and septic system meets the requirements
of the Municipality of Anchorage for residential use as of the day
the system was tested. There is no guarantee that the system will
continue to meet these requirements. The operational life of all
well and septic systems depends on the local soil conditions,
groundwater levels that may fluctuate during the year, and the
water usage of the family being served by the system.
INSPECTION APPOINTMENTS
DATE RECEIVED
TIME TIME
TIME
6. TYPE OF RESS NCE
��tt �
DATE DATE -
DATE & 'rK OU
INSPECTOR INSPECTOR -_
INSPE�C CItANCHORAOE F -'
e
ENVIRONMENTAL 1 ,oXECTION
MUNICIPALITY OF ANCHORAGE.
--
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
•
ENVIRONMENTAL SANITATION DIVISION 1/�
��
Telephone 264.4720
j /
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten 00) days for processing..
1. PROPERTY OWNEPHONE
INDIVIDUAL/ON-SITE**
CC 7
❑ PUBLIC UTILITY
MAILING ADDRESS /
PROPERTY RESIDENT (If different from above)
PHONE
2. BUYER
PHONE
MAILING ADDRESS
-
3. LENDING INSTITUTION
� / - /F
PHONE
_�
MAILING ADDRESS
4. REALTOR/AGENT -
�-
PHONE -
MAI LING ADDRESS
5. LEGAL DESCRIPTION
/� v 7
_
STREET LOCATION
6. TYPE OF RESS NCE
- NUMBER OF,BEDROOMS - -
SINGLE FAMILY
O One Cl Four ❑ Other
❑ 0 ❑ Five
❑ MULTIPLE FAMILY
® Three ❑ Six
7. WATER SUPP --_
--
INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUB UTILITY
depth (attach log if available.)
8. SEWAGE DI SAL SYSTEM
INDIVIDUAL/ON-SITE**
zYEAR 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)/I < - t4
1.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE
❑ TWO
❑ THREE ❑ FIVE ❑ OTHER
❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
S -t'b
INSTALLER
K
❑Septic Tank or ❑ Holding Tank
Size: / ri- If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
i
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
d4-- APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
--i -- / & —Y/ -v
BY
0(� --- ",&P
-- I
1.
`z
Olt
1 lc'�Ir ams�� s
June 17, 1980
825 "L" STREET
ANCHORAGE, ALASKA 99501
(907) 264-4111
GEORGE M. SULLIVAN
MAYOR
DEPAR T MI -N I OF HEAL. T H AND ENV] RONMENTAL PROTECTION
Herzog Construction
2418 East 20th Avenue
Anchorage, Alaska 99504
Subject: Lot 4 Block 2 Olsen Heights Subdivision
Approval for your individual sewer and water facilities
can not be granted until the following items have been
completed:
(1) The water analysis report be delivered to this
depart=ment from Chem Lab, 5633 B Street, for
our review. S
(2) A well log submitted to this department for our
review.
(3) ,The depression or pit around the well casing needs
to be filled with impervious type soil so that it
slopes away from the well casing.
(4) The top of the well casing sealed with a sanitary
seal so that it is air. tight.
Please notify this department for a re -inspection when the
noted descr_epancies have been corrected. If there are any
further questions, please call this office at 264-4720.
Sincerely,
Robert C. Pratt, R.S.
Associate Specialist
RCP/ljw
cc: Alaska Statebank 1
310 East Northern Lights Boulevard 99503