HomeMy WebLinkAboutROBIN HILL #3 BLK 3 LT 9Aug 03 22 10:01 p Anchorage Well & Pump Ser 9072430742 p.1 MUNICIPALITY OF ANCHORAGE V) � vv Development Services DepartmentPhone: 907-343-7904 On -Site Water & Wastewater Section CoMf)�: Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: Parcel Identification Number: 017 394-09 Date of Issue: n_ Legal Description ROBIN HILL#3 Block 3 Lot 9 Property Owner Name & Address: HILL STEPHANIE J 13100 ALGARIN CIRCLE ANCHORAGE, AK 99516 Pump Installation Date: oa - 'A< - 2022 al Ni" Pump Intake Depth Below Top of Well Casing: 200 feet Pump Manufacturer's Name: MYERS Pump Model: 3N FL72-8-P4-02 Pump Size: •70 hp Pitless Adapter Burial Depth: 12 feet Pitless Adapter Manufacturer's Name: MARTINSON Pitless Adapter Installer: Well Disinfected Upon Completion? Yes ❑ No Method of Disinfection: PELLETS Comments: Pump Installer Name: _ ANCHORAGE WELL & PUMP SERVICE 7640 KING STREET Company: ANCHORAGE, AK 99518 907-243-0740 Mailing Address: City: State: Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation_ 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 NAME . [] UPGRADE MAILING ADDREI~(~ /,~ ~--~ ~-~ LOCATION DESCRIPTION NO. OF BEDROOMS Wel,~ Absorl~tion area ( Dwelling PERMIT NO. DISTANCE TO: I -f'roP~%~lbl (o t~cop~seo ~-~ Manufacturer -- ~ Mater:~ ,, [ No. of Aompartments [Liq. capacit~n ga]lo~ .......... I Inside length }Width Liquid d[pth DISTANCE TO ~Well ~ Dwelling PERMIT NO. Manufa~~ ~ ~ Liquid capacity In gallons Well m Foundation -- I Nearest lot line ~ : PERMIT N 01 DISTANCE TO: I F~opoS¢ F Fo Po ~6~ I bo No, of lines I Length of each line Total length of lines I Trench width ~ Distance between lines Top of til~ to finish grade t · i Material beneath tile ~y Total effective ausor~t~on Length [ Width D~th PERMIT NO. Tgpe of cfi Crib diameter Cfi depth Total effe ire absorption area I .~TAN~E TO. ( ~ Well/ B~ation Nearest Io~~ ~ ~_ I~pth Driller Distance to lot line IPERMITNO, ' OTHE8 / SOIL T~T RATING REMARKS L DATE LEGAL PERMI 1- NO. F. L I CRNT L ]]STION LEGRL DEPRF.'TMENT '~--'f, HERLTH RN[:, EN',,'IRONMENTRL ';~'*:OTEC:TION~,-~ ~/'~C\ · --~- , ' - , ...... ,. ~. '~. ~ ~CO ._5 L--A' ' d...' .... '-'L. '-,TREET., HNbHURFt.=E., HI ...... ~ ...... -: . %~ 264- ~t720 ,,~' ~ ON--~ $'; :]: -rE '_--;E ~.-~ E R F' i F." ['-1 ][ 'l \ \., \~- .TFIF"IE'-q JFICKSON PL'I - 'l ..':1 - '-'"' MT. F'LFtL':E LOT '9 E:LI'::'. 3: RABIN HILL SUB :if._-'-': TYPE OF SOIL FtE:SORPTION SYSTEF1 IS: TRENF:H MI-'~>::IMIJM NUMBER OF EE[,R'"FMS  5-0966 LOT _,I,=E 4'~:~.-~ SL.]URRE FEET SOIL R. RTIr-.IG ,.,2:..~ FT,-."BR)= 3:3:O ]"HE REC!UIRE[:, SIZE OF THE SOIL ABSORPTION SYSTEM IS: [:. EF'I~H= :"J_ ,~$ k E 11'-4 C~ TH=: THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF FI TRENCH OR PIT IS THE DISTRNCE BETWEEN THE 5I, JRFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRMFITION (IN FEET). THERE I~ NO SET HIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OLITFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). PERMIT RPPLICFINT HRS THE RESPONSIBILITY TO INFORM THIS DEF'RRTMENT DURING THE !NSTRLLFITION INSPECTIONS OF 8NY WELLS RDJRCENT TO THIS PROPERT'¢ RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. BRCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION 8ND RPPROVRL BY THIS DEPRRTMENT WILL. BE SUBJECT TO PROSECUTION. MINIMUM DI~TRNCE BETWEEN R NELL RND RNY ON-SITE 9ENRGE DISPOSRL SYSTEM 10C~ FEET FOR R F'RIVRTE WELL OR t50 TO 200 FEET FROM 8 PUBLIC NELL DEPENDING UPON TFIE TYPE OF PUBLIC NELL. MINIMUM DISTRNE:E FROM R PRI',,,'RTE WELL TO R PRIVRTE SEHER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MRY RF'PL'¢. SPECIFICRTIONS RND CONSTRUCTION DI8GRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. F'EF:~"I I T E::-::F" I F]ES [:,FZC:Ef'IBEE: I CERTIF'¢ THRT :1.: I RM FRMIL!RR WITH THE REQUIREMENTS FOR ON-SI'rE SEWERS RND NELLS RS SET FORTH BY TFIE MUNICIPRLIT'¢ OF RNE:HORRGE. 2: t WILL INSTFILL THE SYSTEM IN RCCORDRNCE WITH THE CODES. ~:: I UNDERSTAND THRT THE ON-SITE SEWER SYSTEM MRS' REQLIIRE ENLRRGEMENT IF THE RESIDENCE !S REMODELED T~'~CLIJDE MORE THAN 3: BE[:'ROOMS. _ ix: _r_~. = T~__~=~...q ......~--==--~~ ..... ~ ....y ...... MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: '.,,~ 2 3 5 6 7 8 9 10 11 12 13 14 15- 16- 17- 18--- 19- 20- ~ O. Talbot No. 4069~ E SLOPE SITE PLAN / / ENCOUNTERED? O P E IF YES, AT WHAT ~ EPTH? ~ . Gross Net Depth to Net ~Readmg Date Time Time Water Drop s~ ,, ~¢:~ ~o ~r/~,, /~" PERCOLATION RATE · TEST RUN BETWEEN ~,,~0 (minutes/inch) '~ FTAND (~ FT RETURN TO: ~lvfslo~ bF Geological and (~'a'~yslcal' Z Surveys °3001 Porcupine Drive (Tell, let 277-6615) Anchorage, Alaska 99501 WATER WELL RECORD Drilling Company Name STATE OF ALASKA DEPARTMENT OF NATUP~RL RESOURCES U.S.G.S. Local Iio. Drilling Permlt No. No. LOCATION OF WELL J Please complete either la, lb, or I,~: ~'~'~ ..... la. Borough Subdivlsionl Lot Block lb, Fraction Section No. Township Range Meridian lc. Distance and Direction from Road Intersections 3. OWNER OF WELL: ; Completion Materlal Type Top Bottom fL, i } [ ; ~' :; ~ !! · ]: :: ~:': '[ :" []Auger []Jetted []Bored []Other: · ': : ' 6. USE: J~J'Domestlc [--JPublic Supply i--J industry ,~. 7. CASING: Threaded Welded · in. to ft. Depth Weight lbs/ft. 8. FINISH OF WELL: Slot/Mesh Size: Length: Set between ft. and ft. ~. STATIC WATER LEVEL: Ft. [~Above []8elo~ land surface Type of Measurement: 10. PUMPING LEVEL beto~ land surface ft. after hrs. pumping g.p,m. ft, after hrs. pumping g.p.m. MUNICIPALITY OF A qCHORAOE DEPT. OF HEA_TH & ll, WELL HEAD COMPLETION: [] In Approved Pit Matmrial: []Nea~ Cement []Other: Length of Drop Pipe ~ ft. capacity ~g,P-~ Type: []Submersible J-~Reci~rocating []Jet F-Iother: lq. REMARKS: 5. WATER WELL CONTRACTOR'S CERTIFICATION: ~ This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Registered Business Name Contract License Number Signed: 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. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING - _'z)°l L~ - I~C~ NAA# ~1 ~q ~r') r~~ ('~ .-~ 1. GENERAL INFORMATION Complete legal description Lot 9; Block 3; Robin Hill Subdivision #3 Location (site address or directions) 13100 Algarin Circle 4: Property owner Mailing address Lending agency Mailing address Carl & Dee Jumper '13100 Al~arin Circle Anchorage, Day phone 345-4477 Alaska 99516 · Day phone AgentPRUDENTIAL RELOCATION c/o Fortune Properties, Inc. Address 30nn A ~tr¢¢t #101 z.~bo~g2, Attn: Marq Ann Bec~with Day phone 562-7653 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well NOTE: Community well Public water 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 NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown belowi I verif~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. s & s ENGINEERING 17034 Eagle River Loop Roa~ Eagle River, Alaska 99577 Phone Name of Firm Address Engineer's signature /~,,-~.,)bed roo ms. DHHS SIGNATURE ~ Approved for Disapproved. Conditional approval for Date bedrooms, with the following stipulations: Additional Comments 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 engineer's work. 72-025 (Rev. 1/91) Back MOAi¢21 Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /_ol' c~r ~LY..~/ ~°6~J ~'/O ~ Parcel.I.D. _~../~-- A. WELL DATA Well type '~L~O~F_ Log present (Y/N) Total depth Sanitary seal ~/N) If A, B, or C, attach ADEC letter. ADEC water system nUmber Date completed L'([lc~[~( Driller Cased to ¢~'3o° / Casing height Wires properly protected (~'N) FROM WELL LOG Date of test z-//]c~/~ t Static water level ~.2. ) Well flow ~ Pump level ~ ~,~ AT INSPECTION g.p.m. ~ g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main ~'J/~- Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank //~/U~ WATER SAMPLE RESULTS: Coliform (~ Nitrate Date of sample: ¢-?-- / ~ 0 (/~°J~~ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~/$~,~\ Tank size 1~50 ~_~-A~__ Compartments Cleanouts ((~N) YE.~ ~ Foundation cleanout~N) ~ ~ Depcession (Y/~ High water alarm (Y/N) ' ~ "Alarm tested (Y/N) Date of PumpJng ~/~/~ . ,: Pumper A~ ~ SEPARATION DISTANCES FROMSEPTIC/~NK TO: Well(s) on lot [0~ ~ On adjacent lots ~ TO property line ~b~.% r+ Absorption field Surface water/drainage [00 ¢ Foundation Wate~ main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION /U//~~ D~ Manufacturer Size in gallons "---.. ~ Manhole/Access (Y/N) Vent (Y/N) "Pump "-tev~.~ "Pump off" level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) ~ SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed 3/-~l Soil rating Surface water .~0 Gravel thickness Cleanouts present (~,N) Date of adequacy t~st for ~l'oOOO ~ If yes, give date Length ~' [ Width ~ Total absorption area Depression over field (Y/~,~ Results (pass/fail) ~ Peroxide treatment (past 12 months) (Y~ ,//;/**-¢ bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I©O ~c To building foundation On adjacent lots Surface water Curtain drain On adjacent lots /0¢J ~,/- Property line ~-~ '/- To existing or abandoned system on lot Cutban k ~or-.~ Water main/service line Driveway, parldng/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect Signature Engineer's Name Date S & S ENGINEERING 17034 Eagle River Loop Ro~d Eagle River, Alaska 99577 ;ct ,o,.~.t~e date of this inspection, HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 661-5301 "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 Application Date ?-//~/¢¢'~ GENERAL INFORMATION (a) (b) (c) Legal Description (include lot, block, subdivision, section, township, range) I- tLL. -%/f? Location (address or directions) Applicant Name ~0~ &~ Telephone: Home ~ Business Applicant Address 13100 ~LG~I~ C.I~, ~N~ ~ ~1~ Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain); (d) Lending Institution ,"'~/ '''~ ' Address ///~//) (e) Rea~ Estate Company and Agent Address Telephone Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well'S' Community [] 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 [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 ~ IL I~NGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA I'A 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 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 ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~ Address Date Approved for ~ bedrooms by~ ,~ ¢"~.~ ~.,~.- ~ ' Approved ~ Disapprove~d/ -- ' Co'~diti°~rf~l 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 MUNICIPALITY OF ANCHORAGE (MO~) MUNICIPALITY OF ANCHCfI~TH AUTHORITY APPROVAL (HAA) DEPT. OF HEALTH & CHECKLIST - FEBRUARY 1984 ~IVIRONMENTAL PROTECTION WELL DATA NtA¥ 1 2 1986 RECEIVED 264-4720 Legal Description: .l 2.rg '~ ud ~,, h,/_Jz'Tl~ If A, B, C, D.E.C. Approved (Y/N) Well Classification (t~[.~t '';" Well Log Present CH) Date Completed ~/)/¢/'~"[ Yield Total Depth '-~--~ / Cased to ~'-~'~ '/ Static Water Level ~. ~, ~r~ / ~ Casing Height Above Ground ~- / Electrical Wiring in Conduit ff~N) Separation Distances from Well: To Septic/Holding Tank on Lot i ~)/TL- ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot [ O0 /'TL- ; On Adjoining Lots [ O0 /`''/- To Nearest Public Sewer Line /:.¢/~r~_¢Y//~L- To Nearest Public Sewer /V///~// Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ,~ '~,,.,~[~z"j.~(;/(~:.~ ;Date l;//~ r,~)/ Water Sampl,~ Test Results .SPrT(_SPCrc'¢O/~¢ - ~EE- A-7'T/~¢N/~.O_.~ Comments' ' PE , T C-S q/30/ , v Depth of Grouting Pump Set At '~' -~'' ~'~ t Sanitary Seal on Casing ¢,.i //I'~O ~ Depression Around Wellhead (~N) B. SEPTIC/HOLDING TANK DATA Date Installed _"~/~J/~l Standpipes (y)N) Air-tight Caps Depression over Tank (Y/~) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /~///~ Separation Distances from Septic/Holding Tank: To Water-Supply Well J To Property Line To Water Main/Service Line Course ] ~'~) f''~ Size I ~O 0 No. of Cbmpartments ~ Foundation Cleanout ¢.~N) Date Last Pumped ~/~7 Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~;t~ Date Installed.. , ~/~,~ J / e I Width of Field ..~- / Square Feet of Absorption Area Depression ovei: Field (Y.~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot P'C/t~ To Water Main/Service Line Type of System Design Length of Field ~ / / Depth of Field ,/"'/ Gravel Bed Thickness ,/O / Standpipe~ Present ~N) Date of Last Adequacy' Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line TO Existing or Abandoned System on ;On Adjoining Lots i O(') TO Cutbank (if present) 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) J , f //I "Pump Of,'~__ h///d / ~-~f'~i~t (Y/N) __ __ .~,,.~..-/ Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** SignedI certify that I ~F~'~ke~" v~gfified"Cr c°nf°rmed t° all MOA and HAA guidelines in effect °n the date °f this inspecti°n' ~'9.[~'~?,?,?~_/~/J/d'.~- Date ~ ~,,~,,/,,~/~'P ~'~ . Receipt NO. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) ALASKA el liJIROFImeFITAL COFITROL I~n§ineerin§ 8 ~noironmcntal InC. 05/06/86 MARY D BEAUCHMAN 13100 ALGARIN CIRCLE ANCHORAGE AK 99516 60186 SELLER-JOHN & LUCILLE RENSE MARY D BEAUCHMAN 13100 ALGARIN CIRCLE ANCHORAGE AK 99516 LEGAL:ROBIN HILLS #3 BLK 3 LOT 9 ADEQUACY TEST FOR SEWER SYSTEM ADEQUACY TEST DATE-5/5/86 THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 1220 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 2000 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 3 BEDROOM HOME. SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR THIS 3 BEDROOM HOUSE. THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON 5/5/86 . THIS REPORT DOES NOT VERIFY THE INTEGRITY OF THE PIPING FOR THE WATER SUPPLY OR WASTEWATER SYSTEM. FLOW TEST ON WELL WELL FLOW DATE-04/30/86 A FLOW TEST WAS PERFORMED ON THE WELL. 819 GALLONS OF WATER WAS PUMPED AT A RATE OF 5.85 GPM OVER A DURATION OF 2.5 HOURS. THE DRAWDOWN WAS 5 ' WITH A RECOVERY TIME OF 10 MINUTES AND THE STATIC WATER LEVEL WAS 225.9 FEET. THE WELL IS ADEQUATE FOR THIS 3 BEDROOM HOME. ~onn II1o.~ a-~J A ....... q,,il~ g. AnrNnr..~ Alnd. qnsnq.rnn7/ ALASKA ENVIRONMENTAL CONTROL SERVI ,~} INC. 1200 West 33rd Avenu~'Suite B ANCHORAGE, ALASI (907) 561-5(' SHEET ~0 OF .... m RY DATE ts cs 99507 D,a~T E RECEIVED - INSPECTION APPOINTMENTS TIME ~ TIME TIME DATE DATE ~.[ ~- ~) DATE INSPECTOR INSPECTC~/ INSPECTOR DEPT. OF HEALZEI & ~UNICIPALITY OF ANCHORAGE ENVIRONMENTAL P2OTECTION  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 LStreet-Anchorage, Alaska 99501 O~J~ ~ 5 1981 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 R E C E ! V E D 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 {10} days for processing, PROPERTY RESIDENT (l~-Sifferent from above) PHONE PHONE 2, BUYER MAILING ADDRESS MAILING ADDRESS 5. LEGAL DESCRIPTION J STREET LOC~,TI OTq ~ 6. TYPE OF BESIDENOE NUMBER OF~BEDROOMS ~ One ~ Four ~SINGLE ~ Two ~ Five FAMILY ~ MULTIPLE FAMILY ~Three ~ Six [] Other 7. WATE~ SU~LY J;~ INDIVIDUAL* [] COMMUNITY [~] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled · since June 1975. For wells drilled prior to that date, give well depth (attach log i~f available.) 8. SEWAGE DISPOSAL SYSTEM ~' INDIVIDUAL/ON.SITE~* [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) / THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [~"~O U R [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL ~ COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] ~NDIVI DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER I~lSeptic '[-ank or [] Holding Tank Size: (' ~' ,,~1 If Tank is homemade SOl LS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS ~APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED