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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 PHONE
. [] UPGRADE
LEGAL DESCRIPTION
Well ~ I Absorption area Dwelling PERMIT NO.
r~ ~: D STANCE TO: v...~/~ 0
I- 2 Manufacturer ~.] Material No. of compartments
Liq. cal~a~)tl~.~aIIons IF HOMEMADE: Inside length Width Liquid depth
i~, v Well Dwelling PERMIT NO.
DISTANCE
TO:
~0 ~ ~ Manufacturer Material Liquid capacity in gallons
¢3 Well Foundation If Nearest lot line PERMIT NO.
,--I,, ~. DISTANCE TO: _.~L/00
i~,[ z~ No. of lines Length of each line Total length of lines Trench width Distance between lines
4' inches
I"~r~ Top of tile to finish grade '~ I Material beneath tile L~/ inches Total effective absorption area
Length Width Depth PERMIT NO.
,~ F- Type of crib Crib diameter Crib depth Total effective absorption area
u~ Well Building foundation Nearest lot line
u~ DISTANCE TO:
.~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER {~1
PiPE MATERIALS t
SOIL TEST RATING
INSTALLER
REMARKS
APP~cI ~~ "~ ~'~'-O~DATE LEGAL
DEF'RRTME'N7' I~HERLTHI HN[:, EN, IR_NMENTRL '--"C.'TE3:Tt"-N
........ :,~REE f., ANCHORAGE, BK. ~'~*~..i~
,2,'~ '"L '- ' ' '"' -- -
F'ER. MIT NO. ,- ,-,.,~=~4~.,~., ~ /¢0 ;¢~
RFFLI_.HNT GOENTZEL BUILDERS INC B_,,., ~02.J~8 c"t STN
LI]CRTION FETRIFIED TREE CIRCLE
LEGRL L7 BI REE. KHILL LOT =,I~E ,4.~:0R~ :,QURR. E FEE~
'-"¢ IS '- -'
TYPE OF SOIL 8BSORPT!ON ~x~,TEM : T~EN..H .~. ~:,
M~::'(IMU~ NUMBER OF BEDROOMS = 2~ SOIL RSTING (S~ FT/BR)=~ 85
THE REQUIRED SIZE OF THE SOIL RBSORF'TION SYSTEM IS:
E:. E P T F-t == 7 ILE I%~c_~"l~] :." == 132 ~3 F-: R'-.-' E L E:. E P ]F i-t;= 4
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND AND THE BOTTOM OF THE EXCRVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL. DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRL. L PIPE
RND THE BOTTOM OF THE EXCRVRTION (IN FEET).
~:...' F£ L--::! LB I F-: E [:, S E F' T ][ K2.':.. T' R ~'-.I F=:: S ]l Z E == :IL ~Z', ~-3 ,.;:9 Ci R L L mi I'--! '_~;
PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE
INSTRLL, RTION INSPECTIONS OF RNY WELLS RDJRCENT TO THIS PROPERTY RND THE
NUMBER OF RESIDENCES THRT THE WELL WILL SERVE.
8RCKFILL. ING OF RNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVBL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTRNCE 8E7'WEEN R WELL RND ANY ON-SITE SEWRGE [:,ISPOSRL SYSTEM IS
100 FEET FOR R PRIVRTE WELL OR t50 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE T'T'PE OF PUBLIC WELL
MINIMUM DISTRNCE FROM FI PRIYRTE WELL TO R PRIVRTE SEWER LINE IS ;-25 FEET RND
TO R COMMUNIT'¢ SEWER LINE IS 75 FEET.
WELL LOGS RRE REQUIRED RND MUST BE RETURNED 7'0 THE DEPRRTMENT' WITHIN ~0 DR'CS
OF THE WELL COMPL. ETION.
OTHER REG.,UtREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRFIMS RRE
RVRILRBLE TO INSIJRE PROPER INSTRLLRTION.
F-~ERfd I T E:..-=:P I RES [:.EL-~..EPIBEE:
I CERTIFY THRT
$: I FtM FRMILIRR WITH THE REQLIIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET'
FORTH B'¢ THE MUNICIPRLIT¥ OF RNCHORRGE.
2: I WILL INSTRL.L THE S'¢STEM IN RCCORDRNCE WITH THE CODES.
Z.:: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MR'¢ REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THRN 2: BEDROOMS.
RFPLI ]:RNT 3EEN~EL E, UILDERS INC
V4. 0
PERFORMED FOR:
LEGAL DESCRIPTION:
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COMMENTS
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
d-~ oE-,o/--'z-~d ,~/__~/4..5 o*TE PERPORmD:
SLOPE SITE PLAN
soILs LOG
[] PERCOLATION
TEST
Gross Net Oepthto .
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN , . FT AND FT
Depth o~ well ~¢
Dfst~ee to water while pumping ~7 /
....................................................... at rate
of. ~f~?. ................. gallons per hour.
F°rmation from to
MUNIC[F ~LITY OF ANCHORA
ENVIROi MFzNTAL PiRO/~.CTI¢
R
DELTA DRILLING COMPANY
SRA BOX 394 B
ANCHORAGE. ALASKA 99507
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 '~r'/'l ~ ,/,~/~
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name' ~o~o ~""l¢~-~)
Applicant Address ~¢ ¢¢.
Applicant is (check one): Lending Institution ~; Owner/buitder~; Buyer ~; Other ~ (explain);
Telephone: Home :~ .¢~. 2 -2,3.5'" Business
(d) Lending
Address
Telephone
(e) Real Estate Company 'and Agent
Address
Telephone
(f)
Mail the HAA to_.t.be-f~Je~ing address:
TYPE OF RESIDENCE
Single-Famiiy,l~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well [~ 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.
~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 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 ali Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm ./~J-¢~, w '~-'Jl ~ r'¥ ~-
Address '-.) t ~ ~ ~ g
Date ~ ~1'
~&TER ~ELL NOTE: Th~s Health Authority Approval inspection
certifies that the subject ~ate~ ~e]] produced ~50 ga]Ions per
bedFoom or moFe on the date o¢ testing and that certified
tests sho~ed no presence of coliform bacteria in a sample o¢ that
~ate~. No uarantee ,o~ certification is expressed o~
concerning the long teFa adequacy oF safety o¢ the ~ater supp]y.
Telephone ~'-,~'¢+ ~¢- '~- 7 11
ON-SITE SEWAGE DISPOSAL SYSTEM NOTE: This Health Authority Approval
inspection merely certifies that the subject on-site sewage disposal
system accepted at least 150 gallons of water per bedroom on the
date of testing as determined by methods approved by the Municipality
of Anchorage Department of Health and Human Services. No warantee
or certification is expressed or implied concerning the long term
adequacy of the on-site sewage disposal system. Construction data
reported on buried system components is from MOA files and was
not verified during this inspection.
Approved ~-~' Disapproved Conditional
Date
Terms of Conditional Approval
CAUTION
The Muncipality of Anchora. ge 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.
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
/
Legal Description:
APR i
RECEIVED
WELL DATA
Well Classification ~,, ~;z 5, If A, B, C, D.E.C. Approved (Y/N)
We Log Present (Y/N) Y Da:~te Com_ple~ted r~ ~ /,;Z ~<"-/~ ! Yield
Total De th ~:7 (.L~) Cased to Un k-,c,~'/*"Depth of Grouting
Stat c Water Leve 3~ ((-~.) Pump Set At ¢2,,/-~,.,~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
/ 2." Sanitary Seal on Casing (Y/N) ~/
Depression Around Wellhead (Y/N)
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole ~/,/
Water Sample Collected by
Water Sample Test Results ,.~
Comments 'T~.<.~L ~,-,~.-IL¢ ~'~ "7~
; On Adjoining Lots
/~. "-~ ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on
B. SEPTIC/HOLDING TANK DATA
Size
Date Installed
Standpipes (Y/N) )/ Air-tight Caps (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 > ~o~
To Property Line ~' 2_o
To Water Main/Service Line · ~7¢/''/- Course /L)/~)
No. of Compartments ~
y Foundation Cleanout (Y/N) Y
Date Last Pumped 'flL/[} //4¢~
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation ,-v ~ /
To Disposal Field ~ ~
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
/
Gravel Bed Thickness .~.
~ ~-,.~ Standpipes Present (Y/N)
Date of Last Adequacy Test
Type of System Design
Length of Field .~.S" ~:
Depth 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 ,)' t,'2/2 /
To Building Foundation
Lot
To Water Main/Service Line · "¢O (4-
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line ,.',.. _~1 '
To Existing or Abandoned System on
; On Adjoining Lots /J/~
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..` e/~y~r conformed to a,I MOA and HAA guidelines in effect on the date of this inspection.
Signed ~,.'//~-,'~JJ~/./~ ~ Date
Company ./b/-//~, '-~ ¢/'~ ~ ~' ~,
Receipt NO. ~
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
APPLI¢ ', IT FILLS OUT UPPER HA[ '" ONLY
Buyer
Address Zip Code
Address Zip Code
Phone
Realty Co. & A~nt
Address Zip Code
Type of Resi~nce
Single Family
Multiple Family No, of Bedrooms
~ Other
Water Supply
Individual ~ ~.( ,.-,,~ A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975.
Community For wells drilled prior to that date, give well depth (attach log if available).
~ Public Utility
Sewer Disposal
~ Individual Year individual Installed:
~ ~ Public Utility When Connected to Public Utility: '
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspect°~'~ . _ _~i
Field Notes: MUNICIPALITY OF
, oT CT ON
RECEIVED
< ~ ) APPROVED BEDrOOm8 'OOND~T~ON8 OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
DATE ~~ ~
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
~ -- ~ Well to Tank ~ ~ Septic T~k Size
D,,. :: RECEIVED
[ '~' INSPECTION APPOINTMENTS ~/~.},-~;~.2 ~
TIME ~ TIME TIME /
D,~TE DATE DATE
INS.ECTOR ,NSPECTOR ,NSPECT
MUNICIPALITY OF ANCHORAGERoTECT~MtJNICIPALITYp o~ OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL
DEPT. OF I.!~ALTIt &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION
ENVIRONMENTAL SANITATION DIVISION S~:~P 1 ~ ~981
Telephone 264-4720
REOUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE~~E D
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
PHONE
I. PROPERTY OWNER
MAILING ADDRESS
PBOPERTY RESIDENT (If different from above) PHONE
PHONE
MAI LING ADDRESS
3. LENDING INSTITUTION ~ PHONE
I
MAILING ADDRESS
4, REALTOR/AGENT ~ PHONE
BAILI~ ADD~ESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE [~' SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [] Four
[] Two [] Five
{~'~Three [] Six
[] Other
7. WATER SUP~PLY [~ 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 if available.)
8. SEWAGE DIS~qOSAL SYSTEM
~/I N DIVI DUAL/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
~II~IG L E FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
I~/~NDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
I~]~Vl DUAL/ON -SITE DATE INSTALLED
r--iPUBLIC UTILITY '~. ~...- ~ -~
Connection Verified. INSTALLER
E~]Septic Tank or []Holding Tank
Size: ~' .'~-~ I~ Tank is homemade SOILS RATING
give d~menslons:
TYPE OF TANK MANU FACTURER~,~..~..~....~.
TOTAL ABSORPTION AREA MATERIAL .~' ~
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
,J~APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
September 17, 1981
Goentzel Builders
Post Office Box 10-238
Anchorage, Alaska 99511
Subject: Lot 7 Block 3 Rockhill Subdivision
Approval for the individual sewer and water facilities
cannot be granted until the following items have been
completed:
)
(2)
(3)
The water analysis report needs to be submitted to
this office from the Chem Lab, 5633 B Street, for
our review.
The depression around the well casing needs to be
filled in with impervious type soil so that it slopes
away from the casing.
The area over the septic tank needs to be filled in
with dirt.
(4) The cleanout to the line between the tank and the
trench needs to be repaired.
Please notify this office for a reinspection when the
noted descrepancies have been corrected. If there are
any further questions, please call this office at 264-4720.
Sincerely,
James S. Roberts
Associate Environmental Specialist
JSR/ljw
cc: United Bank Alaska
645 G Street 99501