HomeMy WebLinkAboutRAYMOND TEDROW BLK 5 LT 3DRaymond
Tedrow
Block 5
Lot 30
#050-155-51
JUL 19 2013 `
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: OSP131174 PID Number: 050-155-51 ❑ New ❑✓ Upgrade
Name:
Mark and Patti Tittle
ABSORPTION FIELD
El Deep Trench El Shallow Trench ❑Bed ❑Mound
Address
19230 Bernard Road Eagle River, AK 99577
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
GPDISF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original gradeGravel
depth beneath pipe
Subdivision Block Lot
Raymond Tedrow 5 3D
Ft,
Ft.
Fill added above original grade
Gravel length
Township Range Section
Ft.
Ft.
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ftp
Ft
Well
>100,
>100'
N/A
N/A
>25'
TANK ❑ Septic ❑ S.T. E.P. ❑ Holding ❑ Other
Manufacturer
Anchorage Tank
Capacity
1 1,250Gal.
Surface Water
>100'
>100'
NIA
N/A
Material
Number of compartments
Lot Line
>5'
>10'
N/A
N/A
Steel
Two
NA
Foundation
>5'
>10'
N/A
NIA
LIFT STATION
Manufacturer
Capacity
Curtain Drain
None
Noted
Gal.
Remarks Tank Only Replaced Under This Permit.
Pump on level at
Pump off level at
High water alarm at
Existing Tank Decommissioned in Accordance With
in.
in.
in.
Municipal Code.
Pump make and model
Electrical Inspections performed by
Installer
PIPE MATERIAL Housetotank D3034 Tankto
drainfeld D3034
Stuart Gilbert
DrainBeld HDPE COtMT D3034
Inspector JKB
BENCH MARK (Assumed elevation) 100.08
Inspection„
dates: 7/10/13 2- 7/11/13
Location and description
p
aro 0
Garage Slab.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
OF
Conditional Approval: Date
•• ��:• °°4 LgS1 f
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Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number: OSP131174
5.8
00.4
v1 / N UU
1,250 Gallon
Septic Tank
Tank Only Replaced Under This Permit. Existing Tank Decommissioned
in Accordance with Municipal Code.
PROFILE AS -BUILT -
No Scale
PID No. 050-155-51
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:
OSP131174
Tax Code Number:
05015551000
Work Type:
Septic
Permit Effective Dates: July 09, 2013 to July 09, 2014
Design Engineer:
ANDERSON ENGINEERING
Subdivision:
RAYMOND TEDROW
7-11-13 0 /():
Site Legal Address: RAYMOND TEDROW BLK 5 LT 3D G:0152
Owner/Address: TITTLE MARK A & PATTI L
19230 BERNARD RD EAGLE RIVER AK 995779036
Site Mailing Address: 11416 FIREBALL ST, Eagle River Lot Size in Sq Ft: 7598
Total Bedrooms: 3
This permit is for the construction of:
N Disposal Field Y Septic Tank N Holding Tank 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
Issued By
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 050-155-51
Property owner(s) Mark & Patti Tittle Day phone 223-4331
Mailing address 19230 Bernard Road Eagle River, AK 99577
Site address 11416 Fireball Street Eagle River, AK 99577
Legal description (Sub'd., Block & Lot) Raymond Tedrow, Block 5, Lot 3D
Legal description (Township, Range & Section)
Lot Size 7598
Sq. Ft.
Number of Bedrooms Three (3)
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial
Single Family (SF)
El
(w/wo ADU)
Septic Tank
Q
Upgrade ElDuplex
ElHolding
(D)
Tank
❑
Renewal ❑
Multiple Dwellings
❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Dis tance:
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: ,r,20[] i'c riG yWaiver Fees: _
Date of Payment: 7 a 113 C � aDate of Payment:
Receipt Number: 614 V1 am
Permit No.�`0j f 1-611, q
Permit App_9-1-12.doc
Receipt Number:
Waiver No.
July 1, 2013
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 3D, Block 5, Raymond Tedrow Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The septic tank on Lot 3D, Block 5, Raymond Tedrow Subdivision has collapsed and
must be replaced. We are proposing to replace the tank with a new 1,250 -gallon steel
septic tank to serve the three-bedroom home on the lot. We are therefore requesting a
permit be issued for the construction of a new septic tank to serve the home. The
attached Site Plan and backup documentation identify the location and configuration of
the existing septic system and the location of the new tank. Also identified on the plans
is the existing water on the lot. The subdivision is served by a community water system
and no conflicts existing between the proposed septic tank and other septic systems in
the area. The existing tank on the lot will be properly disposed in accordance with
Municipal code. The drainage patterns on the property will be maintained after
construction.
The ground surface on the lot slopes to the east at a shallow grade in the area of the
new tank. The new septic tank will be constructed near the location of the existing
septic tank and tied in to the existing service line. The tank will be constructed in
accordance with Municipal requirements.
If the tank is constructed in accordance with our design the following statements apply:
The tank, if constructed as designed, will have no adverse impact on the wells in
the area or those to be constructed in the future.
2. The tank, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
Lot 3D, Block 5, Raymond Tedrow
July 1, 2013
Page 2 of 2
3. The tank, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The tank, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
49th _
MICHAEL E. ANDERSON
No CE -4781
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a MUNICIPALITY OF ANCHORAGE
' ® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
l ENVIRONMENTAL ENGINEERING DIVISION
\ 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME - PHONE
�Isw . � ,; ems, � � I
I�-C�/L�.�-C' �✓ �t?T7' / C '� --- --- C ` _a� -�
-C�YNEW
❑ UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION y/.
NO. OF BEDROOMS
DISTANCE TO:
Well
Absorption area
r
Dwelling
J� �(✓�L
PERMIT NO. n
3, O l l
a Q
W h
Manufacturer,(_-
mater6l ,)
No, of compartments
Liq. capacity in gallons
IF HOMEMADE:
Inside length -
Width
Liquid de III
�-'
DISTANCE TO:
Well
Dwelling
PERMIT NO.
02
h
Man ufac reY - - -�-"- ----Material
Liquidcapacity in gallons
W'ey1 a-Foundation�}--
-(
Nearest lot line
PER(\91T NO. y�
� a Z
a z cc
No. oPf�lines
V /) ��i _
Length of each I e
_ - 0
-
Total length of line
jL_
Trench widIC/�
I inches
Distance hetes en Iii es
h
D _zy•irrelres�Z
Top of tile to finish grade
Material beneath tileC
Total effectiveabsoretion area
[�
ug
Length
Width
Depth -
PERMIT NO.
a I-
W__---�—
Type of crib _. ---Crib
d ameter
Crib epth
Total of - -y`e absorption area — - -
CA W
TA--DTS NCE TO:
Well
Building foundatio
T--_�
Nearest lot
_j
J
CI�/
l/ �J �l1A__
Depth
EDriller
Distance to lot line
PERMIT NO.
W
DISTANCE TO:
—
Building foundationine
—
Septic tank
Absorption areas)
OTHER
-
-
PIPE MATERIALS
_7) 3 Biu
SOIL TEST RATING ,\
(J
—
INST L�jE�R
REMARKS
i
i
i) t
pl
3y
—
i
AP ROVED - � DLEGAL
ATE
72-013 (R�6.3/78) P
'11-11--7 S'IZE OF ITIE SiDIL AB!-.;iDP!PT1C.Q-J S`r'.'I:TEN
1150 Ili 1q -.Z-4 -11- L- Eli 10.1 (.1 -r- 1-0 — :1. -":39 FE F", -r, 9--8
THE LENCUI-] C-11"WhISIO1'4
15
THE LEVIOTH (IN FEE,r) I -IF THE TRENCH OF:
I"HE ClEPT'll OF A
TRI]JICH
r7l 11-- X -11"
N7•711 V-1 IC II-- F-1 C. -i
vo
Boi-rc.im
oF
FEET).
)Cj i (Y)
WIDTH
L REE'f..
W -1C.1-1 ..-.IRA 1-`iE.,
"HEC-EPTH
15 THE
FEE'T.
MU-111,11YI ClEP11.1 CiF j3RFi%,T:L BETWEEI'l THE OUTFALL F'IF'E
il'it-jc- E.:crr,rcwl
CIF.'['HE
E r -.-.T-':
A ATI OP -4 (IN FEE -I").
E -E fl::."A :Y. FZ, IEE ED.
TO It-JSJ-IF:E PF. -!OPER IPTSTALLATi.ori.
C-11 PA 1...V PE...
IE 9 F::4 R! Pek 1 -11-
I'D )
I :
APPLI CANT I%,'EP!S:0N
PO Bi. -i::.:: EAGLE
6..; 9 et 2'-.-': 0. C1
L CIN
F1 Rf..BFILL .!;,r.
B5 P.,AY111aND
I.- OT S12 E 8:E-400
OF
SOIL. ABSOF"1010PA SYSTU'.11 I' : 'VRENCH
MAXIMUM
I".11-111BEF'! IJF 1HEDF.I.00I[11.1---; :- 3
:-01L. (.SQ FI',,`BR'.—
10
'11-11--7 S'IZE OF ITIE SiDIL AB!-.;iDP!PT1C.Q-J S`r'.'I:TEN
1150 Ili 1q -.Z-4 -11- L- Eli 10.1 (.1 -r- 1-0 — :1. -":39 FE F", -r, 9--8
THE LENCUI-] C-11"WhISIO1'4
15
THE LEVIOTH (IN FEE,r) I -IF THE TRENCH OF:
I"HE ClEPT'll OF A
TRI]JICH
OR
F,1'1' IS THE I.)IS'TFihIC:E F-.:E-rI...IEEt-,I -p-JE OF'
Cif : C., U N 1) AND 'r'Hu
Boi-rc.im
oF
FEET).
"I"I-IM.' I'-.; NO SET
WIDTH
FOP.,
TRENCHES.
"HEC-EPTH
15 THE
FEE'T.
MU-111,11YI ClEP11.1 CiF j3RFi%,T:L BETWEEI'l THE OUTFALL F'IF'E
il'it-jc- E.:crr,rcwl
CIF.'['HE
E r -.-.T-':
A ATI OP -4 (IN FEE -I").
E -E fl::."A :Y. FZ, IEE ED.
TO It-JSJ-IF:E PF. -!OPER IPTSTALLATi.ori.
X 0 "T- K 141 IC7 Q 1: : I -Z 1E`:r.L= J.-. HE) CEO C'..Fj F`d L- It— C.11 PA "-,Eu'
PE!"P.P11 T FiFT-1. I CM. -IT HFr-�.- THE RESPONS 11,1 LI Py' TO I NFC)Rlel rH11 f."1EPFIRTME1'•1T DUF'. I Ni. --j ]"HE
INS-11ILLATION INSPECTIONS OF ANY IWELLS ADJAC*1.-1--IT TO 'THIS PROF'EF!T'-r' THE
OF RESIDEI.-ICES 'FHAT THE NE LL.. WILL. -S.;EPv'E.
C--li I II -1q %H,". F-1 E.i 1 Co PA%=.5 F"11 IT! FET FR! EFR a U I n EE- E: -.0
.:IF' At-vT, sysprEll PirrHOLIT FIFAFIL. I Iq 13P E C.'."FIC, P-1 Akll.') APPRI.10-:1AL 13Y TI 11:5
WILL. BE 5'..'E:..YEi:.:T TO PRO,.:.:;ECUTION.
mramm mcwTANCE BETIVEN A
AhIC) FIN Y ot.,i-
siTE DISPOSAL
FEET" A PRI%-'1:1TE WELL OR
-150 TI'D 200
FEET FROM A FUELIC WELL
DEFTRADING
I.JF'ON THF..' T'rVE' OF" PL.If.3LIC 14ELL.
MINIMUM DISTANCE. I". -ROM A PRIvFiTE
WEELL. TO A
LVIE IC.'
23 Ahlr.,�
TO 19 LINE IS 7,•"i
FEE'T.
CIT HEF: MAY APPLY.
AND
DIAGRAIT.-,; FIRE
TO It-JSJ-IF:E PF. -!OPER IPTSTALLATi.ori.
I CEF'.,TT.I:::'1,1 1-1 IAT
1: 1 APP FAMILIFiR, WITH THE REQUIREMP-ITS FOR Ot-.1-SITE ,.,---EwER..S
FORTH I'HE OF
2: 1 1411-1. (PISTAL.L. THE 'Pi'STE11 IN ACCCIRDFINIDE WITH THE
.-.:: I THAT THE ON- -`.1. SEWER SY'S;TEM MAY REQUIRE
RESIDENCE IS; REMODELED To 1NICUIDE P10RE THF -0.4 3 BEI)ROOMS.
5:1 (3 P1 E D
A F, P L I III
.1-
AhI1? WELLS AS SEf
U11-FIRGEMPIT IF' THE
O & E ENGtNEERINC & DEVELOr MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Nrtasell Oyster
694-2774 SOIL LAC
Performed for: Name: r �� Q om' ��'`� �' ���rf61-� Tel.
Mailing Address: l�
Legal Description: - — � �«e o%i�ymeM1 / /
Depth (feet) Soil Characteristics
U
1
2
3 _-
aZl2 A,
4
G vc r_
6
' � Cv
in✓c' �i� � e
7
9 �—
oe")
10
13
14
15
16
Ground Water Encountered: Yes No �� If yes, what depth
Proposed Installation: Seepage Pit Drain Field
Commen
Earl Ellis
688-2280
-0' 3 ac-)
7�5 2 7
PLOT PLAN
PERG. TEST
Performed by: L -J, f 1 (VV i�>`� L--'/'= Date: /- 2i
aZl2 A,
PLOT PLAN
PERG. TEST
Performed by: L -J, f 1 (VV i�>`� L--'/'= Date: /- 2i
MUNICIPALITY OF ANCHORAGE
® DEPARTMENT OF HEALTH & HUMAN SERVICESi�
Division Environmental Services
On-Site Services Section
P.O. Box Box 196650 Anchorage, Alaska 99519-6650
343-4744 �� L �i �y
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
I
Parcel I.D. # 050-155-51 HAA # q
1. GENERAL INFORMATION
Complete legal description Lot 3D, Block 5, Raymond Tedrow Subdivision
Location (site address or directions) 11416 Fireball Street
Property owner Roger & Kathy Gantner Day phone
Mailing address %11,416 Fireball Street, Eagle River, AK 99577
Lending agency
Mailing address
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water xxx
Day phone
Day phone
694-3663
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
xxx
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 fRev. 1/91) Font MOA N21
5. STATEMENT OF INSPECTION BY ENGINEER
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 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.
Name of Firm S & S ENGINEERING Phone 6 c} 'f c� 7 y
17034 Eagle giver Loop Road No. 264
Address
Engineer's signature Date 6 6
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Or �f ,q�t�t`¢
Ze
1 ROBERT C. COWAN
CE
Ar
bedrooms, with the following stipulations:
Date _-5-8 qq
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 orderto 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 MOA a21
RECEwE-,
Municipality of Anchorage APR 2
DEPARTMENT OF HEALTH & HUMAN SERVICES 6 199
Environmental Services Division MUNICIPALITY OF 4NC8
825 L Street, Room 502 • Anchorage, Alaska 99501 • (90�'IR"WMSERVICES DIVISION
Health Authority Approval Checklist
Legal Description: L oT 3 D 8 4- f) c `t 5— Parcel I.D.: (3 S c) — / 5`S` —S` /
kvi 0 -j o j/ %A /L. J ✓ S %�
A. WELL DATA
PU 13�- I c wia-rr 2
Well type If A, B, or C, attach ADEC letter. ADEC water system number /
Log present (Y/N) Date completed
Total depth Cased to Casing he' (above ground)
Sanitary seal (Y/N) Wir roperly protected (Y/N)
FROM WELL LOG AT INSPECTION
Date of test
Static water level
Well production g.p.m. 9—
p.m-WATER SAMPLE RETS:
Coliform Nitrate Other bacteria
D of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed `7 / as-lk Tank size ) a S`c� Number of Compartments Cleanouts(ON) ytf
Foundation cleanout (®N) W, 5 Depression (YAM
Date of Pumping / 6 1 Pumper
C. ABSORPTION FIELD DATA
N High water alarm (Y
)y U
Date installed' 7b-S`� / Soil rating (g.p.d./ft2 or ft2/bdrm ) 0 a System type X40^' SII
Length a -o Width 3 Gravel thickness below pipe g Total depth
2 I vsrAw�tl L/hka-Igei
Effective absorption area /� d r' Monitoring Tube present &N) % �S Depression over field (Y/& ro 0
Date of adequacy test/ `� Result (Pass Fail) 1'4 SS For bedrooms
Fluid depth in absorption field before test (in.); .r Immediately after S ° gal, water added (in.): W 7 '/,y
11
Fluid depth .3 for (ins) Minutes later: G Absorption rate = g.p.d.
Peroxide treatment (past 12 months) (Y/N) N a'j &' 9 "'10&v `/ If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at' _
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level
Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewdr /septic sero
"Pump off" level ate
On adjacent lots
On adja is
ublic sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation '_ 4- Property line S' Absorption field
Water main/service line )0 4 Surface water/drainage Wells on adjacent lots 4
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
r , i
Property line -)V Building foundation %o + Water main/service line 4
Surface water 0 `�
Curtain drain P 0f"' 4 k N o W?,�
F. ENGINEER'S CERTIFICATION
Driveway, parking/vehicle storage area
Wells on adjacent lots / O 0
I certify that 1 have determined thru field inspections and review of Municipal
in conformance wit M • A A uidelines in effect on this date.
Signature Mil ZJ-IV7,, —
Engineer's Name
Date
HAA Fee $ �Q� Waiver Fee $
Date of Payment o �4 �� �� Date of Payment
Receipt Number G'C,��%% �� Receipt Number
72-026 (Rev. 3/96)`
n 9 ROBERT C. COWAN
CE' -8801
are
-
-
DATE RECEIVED
INSPECTION APPOINTMENTS
STREET LOCATION
TIME
TIME „-
TIME
SINGLE FAMILY
❑ One J Four ❑ Other
iTc,,
❑ Two ❑ Five
DATE
❑ Three ❑ Six
DATE
DATE
❑ INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
i
��— �v� -r( C t "
INSPECTOR
depth (attach log if available.)
INSPECTOR\
INSPECTOR �1
Al INDIVIDUAL/ON-SITE**
1��I YEAR ON-SITE SYSTEM WAS INSTALLE .
❑ PUBLIC UTILITY
d_'- 142 1'; l-
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHOP,AGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF HEA.LIH 2
i
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL. KOTECTION
ENVIRONMENTAL SANITATION DIVISION OCT 2 X1981
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWAKcW D
DIRECTIONS: Complete all parts on
page 1. Incomplete requests will not he processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER
PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above)
PHONE
2. BUYER
n
I�cfl!.L v
c)
-I
PHONE
MAILING ADDRESS
3. LENDING INSTITUTJON
t``
'
PHONE
C� cksY a
MAILING ADDRESS
4. REALTOR/AGENT
SL--
PHONE
e_a-
icy
MAILINGADDRESS
1\^ \
S. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
NUMBER OF,BE ROOMS
SINGLE FAMILY
❑ One J Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SUPPLY
❑ INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
L COMMUNITY Su""'`"� {�f
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
B. SEWAGE DISPOSAL SYSTEM
Al INDIVIDUAL/ON-SITE**
1��I YEAR ON-SITE SYSTEM WAS INSTALLE .
❑ PUBLIC UTILITY
d_'- 142 1'; l-
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
❑ SINGLEFAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ 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
DATEINSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL T0:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
6. COMMENTS
Cl ---APPROVED FOR _�_ BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY
72-010 (Rev. 6/79)
