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HomeMy WebLinkAboutKASILOF HILLS BLK 6 LT 1KasI*Iof H1*11s
Block 6
Lot 1
#015-132-36
M&A-" 5/-T//y
Development Servi-ces Deportment
�-� 3uildirc, Safety Division
On-5Ite wcter WcSi'e-water proor GTri
4100 Bragcw Street
F.O. Box 195650
Mark Begich Anchorage, .A 99519-5650
Mayor nnv!•r.inuninr�; onsite
(907; 343 ?404
Pump Installation Log
Well Drilling Permit Number: SW Date of Issue:
Parcel Identification Number:
Legal Description
Prope Owner Name &Address:
\Jason wooq .,
/0(000 Siclora)p La4q tZ..
Pump Installation Date: !f ^ I
Pump Intake Depth Below Top of Well Casing: 560 feet
Pump Manufacturer's Name:
Pump Model: �''tjfQfi�SaJ
Pump Size hp
Pitless Adapter Burial Depth: 10 feet
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer:
Well Disinfected Upon Completion.^ Yes ❑ No
Method of Disinfection:
r/�
Comments: Sats 0jq' wo o4er
Anchorage Pump & Well Service
Pump Installer Name: 330 East 76th Avenue
Anchorage, Alaska 99516
Phone: 907-243-0740
Fax: 907-243-0742
Attention: The pump installer shall provide a pump installation log to the DSD 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 VVNLL INSPECTION REPORT
NAME
IC I NEW
❑UPGRADE
MAI LING ADDR ESS
LEGAL DESCRIPTION
Lo i _RLam"X l2 V, -A 11-0 F 1411,0z
LOCATIONNO.
1 144.,zL , Sra/0V-®
OF BED OOMS
e
y
DISTANCE TO:
Well
Absorption area
Dwelling
P—o
PERMIT NO.
a 1 O 6 S9U
a Z
w I—a
Manufacturer
A C a (' E YA NA
Material
Yt� ld i,_
No_ of compartments
VJ
Lin. rapacity in gallons
F HOMEMADE:
Inside length
Width
Liquid depth
DISTANCE TO:
Well
Dwelling
PERMIT NO.
= Z
Manufacturer
Material
Liquid capacity in gallons
O
w 2
DISTANCE TO:
Well
Foundation
Nearest lot,1ine p
PERMI N
e
J LL z
No. of lines
Length of each jne
Total length Os
Trench width
Distance between lines
F z W
1
(��L, �
,fZ
inches
¢ Fes-
Top of tile to finish grade �,
Material beneath tile
Total effective absorption area
4IR6)
cc
inches
Length
Width
Depth e
PERMIT NO.
Lu
Q F
w�
Type of crib
Crib diameter
Crib depth
Total effective absorption area
LU
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot Ij;1c
PERMIT NO.
w--
DISTANCE TO:
Building foundation
Sewer line
— -
Septic tank
— —
Absorption area(s)
OTHER
PIPE MATERIALS
—
—
CAST WWN I, PVA
SOIL TEST RATING
i
INSTALLER
REMARKS
IN
I /Lem C, /;v
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WE'LL,
6
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)�*:.49T_q
LEGAL
I
{;. •oo••s•oso•o••�.o•ooi•�
• o. 2225_E
1`1UNES ;
APPROVED DATE
ee
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o
' •FSG ���/% �
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l
, �3
t�
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l�;
!ls
THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS:
KA BE: 40`1- 1-1 n a 1-4 ci _T_ H_ sm Q ��M MU, u___ A_
THE LENGTH DIMENSION IS THE LENGTH (IN FEE OR DRHINFIELD
THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE
GROUND AND THE BOTTOM OF 1-1-111--
1" 9 A
HE��A po.":.. -B " IFT: 1117 N Q H_.B BL'.'N 92.�H F" E".��-U
THE GRAVEL. DEPTH IS THE MINIMUM DEPTH OF GR TF
.IE UU[�HLL -`E
HND THE 8OTT0M OF THE T! ON (IN FEET)
-~`---
�EGAU I F'.i"E-_'M�,���'�C 7. -y"101 N P, 1 A too M 120 RA rot A_U W P4�
PERMIT 8PPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE
INSTAL. LHTION OF HNY WELLS HDJHCENT TO THIS PROPERTY HND THE
NUMBER OF FRESIDENCE5 THAT THE WELL WILL SERVE.
����������� ���� ��������� ~�_
BHCKFILLING OF HNY SYSTEM WITHOUT FINAL. INSPECTIONION HND HPPROVHL BY THIS
DEPHRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTHNCE BETWEEN H WELL HND HNY ON-SITE SEWHGE DISPOSHL ';'T'!-- IS
100 FEET FOR H PRIYHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTHNCE FROM H PRIVHTE WELL TO H PRIVHTE SEWER LINE IS 25 FEET HND
TO H CCAMMUNITY LINE IS 75 FEET.
OTHER R�QUI�EMENTS MHY CCNSTRUCTION DIHGRHMS HRE
HVHILHBLE TO INSURE PROPER INSTHLLHTION
Flo i:=": F; v in i v x ��Q Q M 0 EE.: F.��"_" _1_., Q A.
I CERTIFY THHT
1: I HM FHMILIHR WITH THE REQUIIREMENTS FOR ON�SITE SE�ERS HND WELLS RS SET
FORTH BY THE MUNICIPHLITY OF HNCHORHGE
2� I WILL INSTHLL THE '_::;YSTEM IN HCCORDHNC� WITH THE CODES.
]� I UNDERST�N � I E S�WER SYSTEM MHY REQUIRE ENLRRGEMENT IF THE
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«~
DEPHRTMENT
OFHEHLTH HND PROTEC
825 'L'
STREET, HNCIC, Fe. HGE, HK.
264-4720^�
�^��wu�»�����v6
o���oU....�U_.-��Ex���-T������
���U��:D,�U����Fi�� 8�n�.��i��:yv�V'�-�z'
HPPLICHNT G.
CHRLSON
82] WEST5] HVENUE 278'.�]
UNFIT IOh!
/
LEGHL L 1
B 6 KHSILOF
HILLS S/D LOT SIZE ]8000 SQUHRE
FEET
TYPE OF SOIL
HBSORPTION SYSTEM
IS: DRHINFIELD
y `
MAXIMUM
SOTL RATING (SQ 1:5/1130— 125
\v
THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS:
KA BE: 40`1- 1-1 n a 1-4 ci _T_ H_ sm Q ��M MU, u___ A_
THE LENGTH DIMENSION IS THE LENGTH (IN FEE OR DRHINFIELD
THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE
GROUND AND THE BOTTOM OF 1-1-111--
1" 9 A
HE��A po.":.. -B " IFT: 1117 N Q H_.B BL'.'N 92.�H F" E".��-U
THE GRAVEL. DEPTH IS THE MINIMUM DEPTH OF GR TF
.IE UU[�HLL -`E
HND THE 8OTT0M OF THE T! ON (IN FEET)
-~`---
�EGAU I F'.i"E-_'M�,���'�C 7. -y"101 N P, 1 A too M 120 RA rot A_U W P4�
PERMIT 8PPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE
INSTAL. LHTION OF HNY WELLS HDJHCENT TO THIS PROPERTY HND THE
NUMBER OF FRESIDENCE5 THAT THE WELL WILL SERVE.
����������� ���� ��������� ~�_
BHCKFILLING OF HNY SYSTEM WITHOUT FINAL. INSPECTIONION HND HPPROVHL BY THIS
DEPHRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTHNCE BETWEEN H WELL HND HNY ON-SITE SEWHGE DISPOSHL ';'T'!-- IS
100 FEET FOR H PRIYHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTHNCE FROM H PRIVHTE WELL TO H PRIVHTE SEWER LINE IS 25 FEET HND
TO H CCAMMUNITY LINE IS 75 FEET.
OTHER R�QUI�EMENTS MHY CCNSTRUCTION DIHGRHMS HRE
HVHILHBLE TO INSURE PROPER INSTHLLHTION
Flo i:=": F; v in i v x ��Q Q M 0 EE.: F.��"_" _1_., Q A.
I CERTIFY THHT
1: I HM FHMILIHR WITH THE REQUIIREMENTS FOR ON�SITE SE�ERS HND WELLS RS SET
FORTH BY THE MUNICIPHLITY OF HNCHORHGE
2� I WILL INSTHLL THE '_::;YSTEM IN HCCORDHNC� WITH THE CODES.
]� I UNDERST�N � I E S�WER SYSTEM MHY REQUIRE ENLRRGEMENT IF THE
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iICIPALITY OF ANCHORAGE
Department of Health and Environmental r_otection
825 L Street, Anchorage, AN. 99501
264-4720
# HANDWRITTEN PERMIT aE
-Ret/OR ON-SITE SEWER PERMIT
Applicant: co✓>_-C-Mailing Address:
Location: Phone Number: %Y Y3 O 2
LegalDescription: �/ �:7�© /�!� 5�L r�_iLot Size: J 00 U
Type of Soil Absorption System Is:
Trench: Drainfield: _r- _ Seepage Bed: Holding Tank: _
Maximum Number of Bedrooms: Soil Rating(sq.ft/br) Z S
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH GRAVEL DEPTH / WIDTH _
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE _ �6 U GALLONS #
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
# # TWO(2) INSPECTIONS ARE REQUIRED # # #
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 u 1
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will inst 11 t system in accordance with codes.
(3) I u e a the on-site sewer system may require enlargement if
the r ence i remodeled to include more that Y-bedrooms.
Signed: Issued by:
Ap lic fit
Date:
SWP/024 (1/81) 6k- � �®/ (ice
XSOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264.4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: 9 A aril so V) _ DATE PERFORMED:
LEGAL DESCRIPTION: L0 -L I I-- S LdJir (o. 14 *Ls ( "p A 1 its
SLOPE SITE PLAN
-F/
' ORGAEN� C 0 VAR BUatIMN
2
—=-3 • J
• O 6 ''oto
4 -
1
5-
6 6 - rct GRti� f�1 t�1n
7
r
9
r v P to
10 - 1 P a—�
12
a
13-
14
Date
� i
qlxis li.
Net
Time
Depth to
Water
Net
Drop
�)
TH
49
16
17
:, o. 2225-E:.9
JUNE 25, 1971
19-
PTO]
r
COMMENTS
PERFORMED BY:
72-008 (6/79)
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
�GS L
O
P
E
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION / ^ RATE (f��Q � (minutes/inch)
tETrLl RUN BETWEEN
.z"ClQ•0 AT
F.Q.q. cd %e
CERTIFIED BY: II DATE: -7411
_
y -g 7- pe -1
e -s
0
11C %o�Cr . � %� C� iiYj c: r' �a
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:F y:�resm v/ia rRoc'Af c) w rgr'e(�t
7"pr►�.. Rr iso f�1 t'A7 t _'Y,
1p
ONO r 'r
0 SOILS LOG
�- MUNICIPALITY OF ANCHORAGE
% DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
Pouch 6860, Anchorage, Alaska 99602 276.2221 TEST
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: DATE PERFORMED: //-8 -79
LEGAL DESCRIPTION: L.b'- -/ -'.moo
DEPTH I pr�;pn1ca 6tnd Ur�nil ip 3i/fes SLOPE SITE PLAN
�FE(7� 60,, 1 IT
I
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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16-
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Jul .QI. +�.+•+N•a•o••+• U1 AS
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19
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= Richard A. Lowman �
WAS GROUND WATER S —� _ _•__ _ __
ENCOUNTERED? 1�n_ LO,
P--j------I-.- __�—i_. ..._.._� _.-------- ---- --40
Ei
IF YES, AT WHAT
(a0
DEPTH?
1 t
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Not
Drop
I
i
-
p
--G
T
i
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1
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-
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A
WAS GROUND WATER S —� _ _•__ _ __
ENCOUNTERED? 1�n_ LO,
P--j------I-.- __�—i_. ..._.._� _.-------- ---- --40
Ei
IF YES, AT WHAT
(a0
DEPTH?
1 t
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Not
Drop
••°••.<ac=+'+•Q�.�.e► PERCOLATION RATE -(minutes/inch)
Aw
Q'?s�4 TEST RUN BETWEEN FT AND FT
COMMENTS /�f'/ar>;i.,- /�Y/ �G /2/CLQ :2Z/2 ?„/YY.', ..<jT -
PERFORMED BY: CERTIFIED BY: /t//1r,v/NG - Zry AFic�R.c, DATE: //-/O -
'NICIPALITY OF ANCHORAGE
Department c_ Health and Environmental _:otection
825 I, Street, Anchorage, AK. 99501
264-4720
r S # # HANDWRITTEN PERMIT # # 9
t r�(-o WELL PERMIT
Applicant: % LMailing Address:
Location: - _ Phone Number: J-7 o y v
Legal Description:
Lot Size:
Type of Soil Absorption System Is:
Trench: Drainfield: _ Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br)
DEPTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
# REQUIRED SEPTIC(HOLDING) TANK SIZE = GALLONS # #
Permit applicant has the responsibility to inform this department during the
in.stallation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-•s.ite,.sewage disposal system is 100 feet
for a private well or 150 to 200 feet f,iOm a public well depending upon the type
of public well. Minimum distance f-rom:.A private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 3 1
The Required Size.offthe (,Soil Absorption System Is:
J,
LENGTH GRAVEL DEPTH _ WIDTH
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will in 11 the system in accordance with codes.
(3) I un a t t the on-site sewer system may require enlargement if
the yid e .,'/'remodeled to include more t --bedrooms.
Signed: Issued by:
� i --�-
p ,
Date:
SWP/024(1/81)
January 4, 1982
G. Carlson
823 W. 53rd
Anchorage, AK 99502
Permit ` 810605
Subject: Ll B6 Kasil.of Hill
A permit issued by this department for a well and/or sewer
system has expired as of December 31, 1981.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log should be sent to
this department to document the installation date.
If an engineer inspected the installation of the on-site
sewer system, please have them send us the as-bui.lts for our
files.
If there are any further questions, please call this office
at 264-4720.
Sincerely, //��
r4 6S �- -C
Les N. Buchholz.
Program Manager�-
Sewer and Water Program
Enclosure: Copy of Permit
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NHAWTH'.ORNE-ENGINE]-RING
41.0,i—ARM71C BOULEVARD
NhiF,WTHORNE - ENGINEERING S uii-E-eW 5
7 01c] ANGH©RAGE- -ALAS ICA 99503
Anch., AK 99502, 344 4711 90a -77 -l -e09
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Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program a
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak, us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 015-132-36 HAA#_ntA C!5a
1. GENERAL INFORMATION Expiration Date: .-2 — /- D -C
Complete legal description KASILOF HILLS SUBDMSION• LOT 1 BLOCK 6
Location (site address or directions) 10600 SIDOROF LANE * ANCHORAGE. AK 99507
Current Property owner(s) JIM & ANDREA DRAM Day phone 346-2804
Mailing address P.O. BOX 112828 * ANCHORAGE AK 99511-2828
Lending agency Day phone
Mailing address
Real Estate Agent BONNIE MEHNER W/ PRUDENTIAL JACK WHITE Day phone 563-5500
Mailing address 3201 C STREET, SUITE 200 * ANCHORAGE, AK 99503
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
0
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid
water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my
investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. 1 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(are) in compliance with all applicable Municipal
51010 WOOS, o ,110— s, an regu a (ons m e ec a e 1me o
installation -
and.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name ,JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, Ltd. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
_1Z Approved for '7L bedrooms.
Disapproved.
Phone 337-6179
Date 10 f Z4 o 4
Conditional approval for bedrooms, with the fllowing stipulations:
Note: The well for this property meets existing State and Municipal Codes. There are nitrates
be performed to insure the wells continued
present. It is suggested that periodic
Current nitrate concentration is 8.1 mg/L EPA maximum concentration is 10.0 mg/l. More
information on nitrates is available from the On -Site Services Program, at 343-7904.
Attachments:
HAA Checklist Cis Manitenance Agreements
Septic System Advisory Supplemental Engineer's Reort
Well Flow Advisory Other
By: Original Certificate Date:
(Rev. 12101)
�, �GT'flGl
Developm
2.
9 -P.M.
zrnes/100 ml. Nitrate mg /L
vvai
YES
i'Wnn VFX"' "
TU/14/Z004'
1.96 g.p.m
Other bRcterta-C46 colonies/100 ml�
Collected by-, GEG Ltd
4.F;
Date installed 7/21/1981
MAnnniite IVlAn VFC
600+ 9.d
ve date —
Surface wati
Wells on adj
anhole%Pc
High water alarm level.. at in.
_Meets alarm & circuit requirements?
�.'��
On adtacent lots.
8 u�
On adjacacent lots
?Fubl`ic manhole/cleanout w N/A
;.
sewer
Nrf!"¢k.. "YY J,„,,vv�ry�.e�yq.�p$x}rimdznpbnvMm�reu.:bvG
Holding dank N/A
w...
5`+ Absorption field
dine 10'+ Surface water 100'+
e
foo nF -"W6
iefermined t rough field iinspections and Q ,t
records that the above systems are in
IOA HAA guidelines in effect on this date . . , , ..........
A ness:
Ja JEFFREY A GARNESS
QQ �i —7953 ori
p ��o
! a/ %lied n. „p\ e
Waiver Fee $ f e7 jut 1,
777777777777777
Date of Payment _;'!) /27/42y
Receipt Number (G� /•
GARNESS ENGINEER!
CONSULTANTS & GENERAL
October 15, 2004
Municipality of Anchorage
Development Service Department
Building Safety Division
On -Site Water & Wastewater Program
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Septic System for Kasilof Hills Subdivision; Lot 1, Block 6.
To whom it may concern:
We request that your department issue a 5 foot lot line waiver from the northeast property line to
the existing drainfield. I am unaware of any adverse impacts this waiver would have on adjacent
wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you
for your assistatllce.
.E., M.S.
3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: garnessengineering.com
E
of Anehnrac
P.O. Use 196650 • Anchors c. Alaska 99,579-0650 • TEl,tilrone (907) 3$+4-830] • Tlax (967) 343-8200t 4700 Bragaw Street • Anchorage, Alaska 99507 ; r
Mayor Mark Begich `AIXIV'rnr'n' °r'
Building Safety Division
O1 Nov 04
Garness Engineering Group, Ltd
3701 E. Tudor Road
Suite 101
Anchorage, AK 99507
Subject: Waiver Request for Kasilof Hills Block 6 Lot I
Waiver Request #WR040080
Parcel ID #015-132-36
Dear Mr. Garness
Your request for a waiver of the required 10 feet from the Absorption Field to the
Property Line is approved. The approved separation distance is 5 feet.
This waiver approval applies to the existing Absorption Field to Property Line
separations only. Any future upgrade to the on-site wastewater disposal system will
require all separation distances be met or another approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-7904.
Sincerely,
/��tt
Jeff oet
Engineering Tech
On -Site Water & Wastewater Program
Community, Security, Prosperity
S B1.3� 2B.31
SG S
SINGLE FAMILY
FRAME HOUSE /
0
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0000 SHANE
LS-6914 HOLT.- ;G
pgGRE551ONPI' V��
/5 AS-BUILTSURVEY
SCALE: I"= 40'
,
I HEREBY CERTIFY THAT I HAVE PERFORMED A
MORTGAGEE'S INSPECTION OF THE FOLLOWING
DESCRIBED PROPERTY.
LOT 1, BLOCK $, KASILOF HILLS SUB,
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SNOW ANY CONFLICTS BETWEEN
EXISTING STRUCTURES AND PLATTED LOT LIN ES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL ANCH ORAGE RED ORDING D ISTRI CT, ALASKA AND THAT
STRUCTURES OR FENCEIINES. THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT, ARE NOT SHOWN HEREON WITH IN THE PROPERTY LINES AND THAT NO VIS ISLE
NOTE: ANY FENCELINES SHOWN ARE LOCATED APPROXIMATELY AND ARE NOT TO HE USED TO DETERMINE PROPERTY LINES ENCROACHMENTS a IST OTHER THAN NOTED.
OR LOCATE STRUCTURES DATED AT ANCHORAGE, ALASKA THIS _13TH_
ANY PAVING SHOWN MAY BE APPROXIMATE DUE TO SNOWCONDITIONS. DAY OF OCTOBER 2004
HOLT LAND SURVEYING 9507, FB 11487, GPS -2
TEL. 3455513
UTILITY
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SINGLE FAMILY
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0000 SHANE
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/5 AS-BUILTSURVEY
SCALE: I"= 40'
,
I HEREBY CERTIFY THAT I HAVE PERFORMED A
MORTGAGEE'S INSPECTION OF THE FOLLOWING
DESCRIBED PROPERTY.
LOT 1, BLOCK $, KASILOF HILLS SUB,
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SNOW ANY CONFLICTS BETWEEN
EXISTING STRUCTURES AND PLATTED LOT LIN ES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL ANCH ORAGE RED ORDING D ISTRI CT, ALASKA AND THAT
STRUCTURES OR FENCEIINES. THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED PLAT, ARE NOT SHOWN HEREON WITH IN THE PROPERTY LINES AND THAT NO VIS ISLE
NOTE: ANY FENCELINES SHOWN ARE LOCATED APPROXIMATELY AND ARE NOT TO HE USED TO DETERMINE PROPERTY LINES ENCROACHMENTS a IST OTHER THAN NOTED.
OR LOCATE STRUCTURES DATED AT ANCHORAGE, ALASKA THIS _13TH_
ANY PAVING SHOWN MAY BE APPROXIMATE DUE TO SNOWCONDITIONS. DAY OF OCTOBER 2004
HOLT LAND SURVEYING 9507, FB 11487, GPS -2
TEL. 3455513
10-26-04 04:23PM FROM-CT&E ESI SGS ENV SERVICES
9075615301 T-744 P.02/04 F-740
SGS Ref.#
1046774001
All Dates/Times are Alaska Standard Time
Client Name
Gayness Engineering Group, Ltd.
Printed Date/Time
10/25/2004 16:02
Project Name/#
Lot 1, Block 6, Kasilof Hills
Collected Date/Time
10/14/2004 8:48
Client Sample 1D
Lot 1, Block 6, Kasilof Hills
Received Date/Time
10/1'4/2004 14:04
Matrix
Drinking Water
Technical Director _
Steph1C. Ede
Sample Remarks:
Nitrate was analyzed by Mat -Su Test Labs of Alaska.
Pammeter Res"ItsAllowable Prep Analysis
PQL Units Method Container ID Limits Date Date Init
Microbiology Laboratory
Total Coliform 0 col/100mL SM20 9222B A (<=1) 10/14/04 DKC
10-26-04 04:23PM FROM -CUE ESI, SGS ENV SERVICES 9075615301 T-744 P.04/04 F-740
MatoSu
Test Lab of Alaska
Water Quality Testing
Mile 3.2 Palmer•Wasllla Hwy.
P.O. Box 2749
Midtown Community Business Park
Palmer, Ak. 99646
Phone: (907) 746.30115
Email: mat•sutesdati0ronershsa.com Fax: (907) 745.7010
Client SGS Environmental
Date Arrived: 10/15/04
Report Date: 10/18/04
Sample Date: 10/14/04
Attn.: Forest Taylor
Sample Time: 0848
Client ID: 1048774001
Collected Ely;
PVVSID #:
Source:
M.S.T.L.#: 2004970
Sample Matrix:
Comments:
Method Parameter Units
Results MDL Date Prepared Date Analyzed MCL
SM 4500-1403-E NO3 mg/L
8.10 0.50 10/18/04 10/18/04 10.0
Legend: MRL = Method Repon Level
MCL - Max. Contaminate Level
B = Present In Method Blank
R = Estimated Value
H = Above MCL
D = lost to Dilution
r-
R� d ByJon Paul Campdell
Lab supervisor
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 0 /J t 1 - b HAA #
1. GENERAL INFORMATION
Complete legal description La -L 1 �4
Location (site address or directions) 106 U e7 S� JA'ra--Q-
Property owner 116��S C�g 6c� r Day phone
Mailing address 1 0 ('0w
Lending agency t`I & Qe_�T_ F_ %e Day phone
Mailing address -
Agent �aly �1 �aW Day phone -7k-- J77 -L,
Address Pje-c iy v� 1 -70r�- (f�awch��
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: '3 N
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
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:
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 (Rev. 1/91) Front MOA 421
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 / 9�'9 tf �o lai4 Phone
Address o�� 3 l i�/ l J (4 Q
Engineer's signature
6. DHHS SIGNATURE
_ Approved for
Disapproved.
13 bedrooms.
Conditional approval for
Additional Comments
Date
bedrooms, with the following stipulations:
By: 4211 t.l ?CIW Date
NUTIC
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 021
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:''( l 4J Yt `- _ Parcel I.D. �' / `' ' ✓-'
A. Well Data
Well type If A, B, or C, attach ADEC letter. ADEC water system number _
Log present (Y/N) _ ,a Date completed �7 G''y.` f. ' Driller 3 .o . A? f A
Total depth `f Cased to , _Casing height y
Sanitary seal (Y/N) " /
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Date of test '���n Li �r�, / 1 3 MUNIODAUTY nF 4W FIORAUE
/
Static water level ENVIRONMENTAL SER`: K ES U)VISION
_ r)�- � �l
Well flow v° g,p.m. g.P.m. 1 1993
Pump levell F>,5 ` R E i E I `/ E
SEPARATION DISTANCES FROM WELL TO
Septic/holding tank on lot _ f ! ; On adjacent lots
Absorption field on lot %% ; On adjacent lots %
Public sewer main /- Public sewer manhole/cleanout je"fyr•-
Sewer service line �! U Petroleum tank i-1 Ca
WATER SAMPLE RESULTS:
Coliform r> / Nitrate 3, l',�� Otherbacteria(0
Date of sample: yI q/ r),.-3 Collected by: %- J-� <''t• G
B. SEPTIC/HOLDING TANK DATA
Date installed ��/� Tank size Asa Compartments
Cleanouts (Y/N) Foundation cleanout (Y/N) Y Depression (Y/N) _
High water alarm (Y/N) 1`// / Alarm tested (Y/N) �/
Date of pumping A7G Q 3 Pumper _ ;)ej4 t -6t'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot //15 On adjacent lots > /,14E) Foundation
To property line >/O Absorption field
Surface water/drainage i/V
Water main/service line > IL)
72-026(3/93)•Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons_
Vent(Y/N)
��N
.11
N
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
On adjacent lots
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ��� Soil rating (GPD/Ft2) System type C A944_
Length Width !i Gravel thickness f Total depth t1
Total absorption area ��,�lJ Cleanout present (Y/N) �/ Depression over fiield (Y/N)
Date of adequacy test L142 -I Results (pass/fail) for Bedrooms
Water level in absorption field before test
After test 44-• r
Peroxide treatment (past 12 months) (Y/N) If yes, give date
{teen As R. '� : !3��wi vv�✓
SEPARATION DISTANCE FROM ABSORPTION FIELD TO: L
Well on lot On adjacent lots ? % Property line
To building foundation ams To existing or abandoned system on lot
On adjacent lots i [sem Cutbank Water main/service line i
Surface water 1-4 1 C) Driveway, parking/vehicle storage area i 5 C.)
Curtain drain (,j � C,✓
E. ENGINEER'S CERTIFICATION
l certify that I have checked, verified, or conformed to all MOA and HAA guidelines in the'd,�te.of this inspection.
Signature
Engineer's Name VJC.1I'L c,
Date
a�
HAA Fee $ / VAC Waiver Fee $
Date of Payment Date of Payment
Receipt Number` =�?_ ������� Receipt Number.
72-026 (3/93)` Back
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 13 STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562.2343 FAX: (907) 561-5301
REPORT of ANALYSIS
Chemlab Ref.# :93.1676-1
Client Sample ID :1/6 KASILOF HILLS
Matrix :WATER
Client Name :TOBBEN SPURKLAND, P.E.
Ordered By :TOBBEN SPURKLAND
Project Name
Project#
PWSID :UA
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: STUART.
Collected :04/29/93
Received :04/29/93
WORK Order :65496
Report Completed :05/03/93
Technical Director :S
Released By ; APy
@ 14:00 hrs.
@ 14:30 hrs.
EDE
'el
QC Allowable Ext. Ana].
Parameter Results Qual. Units Method Limits Date Date Init
-----------------------------------------------------------------------------------------------
NITRATE-N 3.62 mg/l EPA 353.2/300.0 10 04/30 LLH
* See Special instructions Above UA = Unavailable
** See Sample Remarks Above NA = Not Analyzed
U = Undetected, Reported value is the practical quantification limit. LT = Less Than
D = Secondary dilution. GT = Greater Than
���! 3GS Member of the SGS Group (Soci6t6 Gen6rale de Surveillance)
6751N.0MSN0BLVD.
AHCHO8A8[/ALASKA 99502-JY04
(9O7>279~3916
Municipality of Anchorage May 25, 1993
Division of Environmental Health
Department of Health and Social Services
S20 I Street
Anchoragc, Alaska 99501
SubjectN HAA for Lot i Block 6 Kasilof Hills
Gentlemen;
By researching tIe
files for this, and the
surrounding
lots, I
found a soil log by
Moening Gray, dated 11~10-79`
which
showed no
�ater or bedrock to
15 feet. The location
sketch indicated that
then testhole was
in the general vicinity
of the septic
system.
Other testholes showed
no bedrock or water
down to 12 feet.
One
loti, for lot to Block
4 showed bedrock at 4
feet.
The permit for this
system shows at trench
opLion witt
a total
depth of 8 feet.
My inspection report, dated
7/21/81,
shows a
total depth of 9
feet, with the romment
that insulation
was
placed over the
system.
trench, and additional
fill placed
over the
My interpretation
of the information from
Lhe files is
that the
system was installed
accorJing to the permit,
and that
additiona1
fill was placed over
the system to protect
it from
freezing,
Nothing in the files
indicates that ground
water separation
or
6e6rock separation
is less than required,
.E.
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVI:RONMEN`IA , HEM,11.1
DEP RI'MEW OF HF.AL'1' l AND ENVIRONMENTAL PROTFC`.rION
APPLICA'T'ION FOR HEALTH A IUORITY APPROVAL-, CERTIFI(ATE
1. (pneral Information
Application Date
(a) Legal Daf.::ript-ion (i.ncAu(3e l.ot., block, subdivision, section, to,.Rlship, range)
Lot 1 BLocic 6 ,Kasi_lof Hills Subdivision
Location (address or directions)
10600 Sidoroi Lane
(b) Applicants Name G TC, Carlson and Lois S. Chai)sl_or 'mlephOnxa 346 _3477
Applicants Add-ess SR Box 21.44-D, Anchorage 99507
(c) Applicant is (check one) Lending Institution �� % O.vner./build,=r �� p
{ ,.��._
Buyer 4 Other-� (explai_n);
(d) Lending
Institution
1,arti <°!'
T>�,r
Telephone ; _ /7-i_}
Adctz-ess
;J 7 ': 7
(e) Peal. Estate Cc< & Agent A) /!1
Address
Telephone
2 , 7 of I?r� s idenee
Single -Family Family Other (&l,scribc)
Ntlli bey, of Dedrocnrs
3. Water Supp .y
Individual Nell Ej CcHifnUnity F I I.ublic
Note; If ccATnanity well system, must have written confir_-maticn from the State
Ibpar_tmant: cf Envi-ronzcx=.ntal Conservation attesting to the legality and status.
Is Lhe well adecifate for the number of bedrocafus specified in this HAA (YM) `
4. Sewaqe Disosal.
Ons i-te P-- �I Tkibl is �C Community f—:j Holding Tanlc
I.s the wastewater disposal- system adequate for the number of bedrocros (Y/N)
[Page 1 of 21
2-1.5-84
5. Pngineerina Firm Providinq InSr)9ctions, 'Jhst.s, Data and Information
I certify that E. have
checked, verified, or
corifornrd to all
MOA HAA Guidelines in
erect on the d�te, of
tliis/ inspr_ct.on.
+^ "'
Signed �.._ _
l/ _.Date
,..���•�.� ���
-3 � � =
Name of Fizz "I
f I 0 ;; :Telenhor�
Address = ' 1 2,_
Signed by
Date.—_�
(ENGINEER SEAL)
6. DHEP Approval
Approved for -- — be drocros BY �6_-�-�-
Approved I Disapprow'd. Conditional
Terms of Conditional Approval_
Date T
The Municipality of Anchorage D.�partm-�nt of [bal.th and Environmental Protection does
riot guarantee tha continued satisfactory performance of the water supply and/or the
wastewater disposal system. This approval. indicates that, as of the validation date
shown above, based on the data and information furnished 1y an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and func--
tional for the numter of bedrocxs and type of structure i.rdic.atad.
(DHEP SEAL)
7. Mail the HAA to the following address,
KB2/d5/s
(Page 2 of 21
2-15--84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Lot 1, Block 6
Legal Description: Kasilof H611s Subd.
A. WELL DATA S r i Z12 N P,:3 VV —
Well Classification If A, B. or C. D.E.C. Approved(Y/N) AIM-
Well
rWell Log Present (Y/N) S Date Completed ' -' �_ Yield
Total Depth J9 ° / J� Cased to �,?O Depth of Grouting 11A1KA(61-)1J
Static Water Level% Pump Set
Casing Height Above Ground '31 Sanitary Seal on Casing (Y/N);
Electrical Wiring in Conduit (Y/N) &S Depression Around Nbllhead (Y/N)AIQ
Separation Distances from Well:
To Septic/Holding Tank on Lot /Cka� ; On Adjoining Lots / �
To Nearest Edge of Absorption Field on Lot / ; On Adjoining Lots z6Ln',
To Nearest Public Sewer Line _ZML? To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot DO
Water Sample Collected By 4LZ'11�11'y Dates?
Water Sample Test Results _
Convents
B. SEPTIC/HOLDING TANK DATA
Date Installed -c2/- FZ Size=, No. of Compartments �.
Standpipes (Y/N) ZC; Air -tight Caps(Y ) z Foundation Cleanout (Y/N) K
Depression over Tank (Y/N) AIZ) Date Last Pumped -Ie/ ,5
L~mac!©�a�
Pumping/Maintenanee Contract on File (Y/N) for
_ Alllv-
Holding Tank High -Water Alarm (YM) ,� Temporary Hold ng Tank Permit (Y/N)
Separation Distances from Septic/iolding Tank:
i
To Water -Supply Wb11 /�,� ��"- To Building Foundation
To Property Line ��� �" To Disposal Field_ ZCL) _
To Water Main/Service Line /; �'`c To Stream, Pond, Lake, or Major Drainage
Course N
Comments
[Page 1 of 21
2-15-84
C. ABSORPTION FIELD DATA
e�o,a1V'f�FwFi7 Of ANCtlORA9
DEPT OF HEAUH &
� SAtia.''ng
Soils Rating in Absorption Strata /Q(>�,(�%J,rfi'/�7Type of "SVs�i �sgno"ECTIo1V Fin/ /-
Date Installed Length of Field
Width of Field Depth of Field
Gravel Bed Thickness®
Square Feet of Absorption Area L/ao Standpipes Present (Y/N) )/
Depression over Field (Y/N) NO Date of Last Adequacy Test ��-� �•-���
Results of Last Adequacy Test �,917`er
Separation Distance from Absorption Field:
To Water -Supply Well /Q0 ' ;0- To Property Line _,:5-'
To Building Foundation e;R ' To Existing or Abandoned System on
Lot N On Adjoining Lots 3��
To Water Main/Service Line
"`jr To Cutbank(if present)
,-;,,
To Stream/Pond/Lake/or Major Drainage Course //
To Driveway, Parking Area, or Vehicle Storage Area /!Q '
J �•
Com4*ent5 '1)7%Z3/A/ f /!
r
GUi s �VOTGi 42 7 2- / If 6 r ILs57_e124) X CLAD k-'.7:
D. LIFT STATION IV/A
J
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes(Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA HAAilid�l.,i s in effect
on the date of tis pe ion.
Signed c a'w� . Date
i F 71 �t
Company e- MOA No. 5TJ39 -6)29 f-,
o rENG_ ERs `1
KBl /d5/s
[Page 2 of 21
J
NEIL NA":'"! "..:?I'. F::__
2-n15-84
i ->; r'
L APPLI( AT FILLS
OUT UPPER HA, ONLY
Properly Owner L �, v+, L p (a
Time
Phone
Mailing Address I
Zip Code C11(car
Date
Date
-Buyer(_¢�4`F
Date
Inspector
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Address
Zip Code
Lending Institution-<=c>�>\��s G:>P;.r,.>= <`� �'c,.,, --T
Inspector
Phone
Address+�,a-+�
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Zip Code
Realty Co. & Agent
�
Phone
( ) DISAPPROVED
Address
Zip Cade
( ) CONDITIONAL APPROVAL'
Legal Description
Street Location '-Z A kL, y, Ev
-
Type of Residence
Single Family a
❑ Multiple Family No. of Bedrooms �?
❑ Other
Water Supply
P Individual
ATTACH WELL LOG. A well log is required for all wells drilled since June 1976.
❑ Community
For wells drilled prior to that date, give well depth (attach log if available).
❑ Public Utility
Well Log Received
Sewer Disposal
s6 Individual
Year Individual Installed 't L'4-
❑ Public Utility
When Connected to Public Utility: _
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date j
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
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APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
-
43 ; -9'-
DATE
BY:
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Log Received
6 �
Well to Tank
Septic Tank Size
72023131821