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HomeMy WebLinkAboutKASILOF HILLS BLK 8 LT 15'Bt.r 0 ZO J U 1 ;%'2 1 L 6- a An c. h o -p VVe. I i o puna,) Se 1 p"'; Legal Deser; j,11, �016�4 W\s M U5 1;'rnperf.�y Owner Mime &- Address;. PaInp histallatioul Date: 7,-- 7-7 pUnAr, Intake nepth nfetww'T")p nf'Xell Iasi In: ?-wreel y1 f ]?Ump 'Malr3t2ccurer S Name PUMP Model, Pump Sire. I'MesS Adapter T'1S12J1Pr,. Well Disinfected Upor. No Method of Djsjnfcuij�or: Comments: PC Attention: Tht Pu.'n,- in::*di u 3,Itlt J)SLE -0 P',11110 11,4ti D. log to The DSD within 30 days of- a .D-r,.,p . -toll A F1 .t bevelopment Services Department Buildin.9 at Safety bivision 011 -Site Wal-ar GY Wastew &er Prooratr 47rjo C:Iqlore por P.hyr,- Anchortaoe, AK 95507 —nllr—�ixro,",-1-151t-e- (907) 343-7904 PUMP Installation Log Well Drilling Pei mit Nu,nb,,,j,- S3V--- Date: Of Issue - Legal Deser; j,11, �016�4 W\s M U5 1;'rnperf.�y Owner Mime &- Address;. PaInp histallatioul Date: 7,-- 7-7 pUnAr, Intake nepth nfetww'T")p nf'Xell Iasi In: ?-wreel y1 f ]?Ump 'Malr3t2ccurer S Name PUMP Model, Pump Sire. I'MesS Adapter T'1S12J1Pr,. Well Disinfected Upor. No Method of Djsjnfcuij�or: Comments: PC Attention: Tht Pu.'n,- in::*di u 3,Itlt J)SLE -0 P',11110 11,4ti D. log to The DSD within 30 days of- a .D-r,.,p . -toll A F1 .t ,~~ MUNICIPALITY OF ANCHORAGE li~ ; ,~ 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 '=~AM E [P H~-N E J~EW MAI LING A D ~.~t_ESS LEGAL DESCRIPTION LO~ATION Well Absorption ~,)~ PERMIT ~L.O. ~ ~_~ Meter,.,~ No. ofcompar,ment~ Liq. ciP~t~g.~llons ' IF HOMEMADE: Inside length __ __ Width ~ Liquid depth ..... ~ '" DISTANCE TO: Well Dwelling PERMIT NO, ~O ~ ~ Manufacturer Material Liquid capacity in gallons C) Well u~ DISTANCE TO: ~ ~h,..~]i?~._~ F°unda~ NearestJotline PERMIT~.~*-~ .j ~ Z No, of lines / Length of each Total length of lin~t,,~..~ Trench wid~.b.)/,.,,¢.,.~L-Jinches Distance het!e~.Ils~!ie, ' es~ ~'~_ Topof t,'. to f,,.,sh grade ~, 5.?+~ M.ter,e, beneeth t,,e *ota, ef,ecti t, .,ree ~ Length Width Depth PERMIT NO. <~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ DISTANCE TO: Well Building foundation Nearest lot line ~ Class Depth Driller Distance to lot line ~ERMI-F NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER i PIPE MATERIALS SOIL TEST RATING..., j I INSTAl-hER '~EMARKS APPROVED DATE LEGAl_ ALASKA FNVIRONMENTAL CONTROl. SERVI( , INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 56~.~o4o SHEET NO OF CALCULATED BY~ CHECKED BY SCALE ~ . DATE. 105' ~UELC HElaL. TH Fflq[) F..NV ]: I';.:OI",IH[-:;NTF:IL ' OTECT ): EIf'.,I :~.; T R E E T., la I",1C 1'*10 F':: Ft G E., FI K. 9 9 :...J ::L ,.'2, Ii',.~ ....... ~}:; %. -'ii- E: :F_.'-.';; EC.] ~...l~ IFS{ LOT :E;:[ZE i'iR;:.:;];HLiiq i'.,tlJHE:EF~: OF BEDROOI,tLE; == 5 .~;F'lIl.~ IRlaTIN6 <:5I;! F'T,.'BF.:>=:: 2d..4 THE F;:EI.i:!UZF;:ED ::};ZZE OF:' 'THE: THIE LENGTH [:, I HEt",IE~; I ON :ii :~ 'THIE I....ENGTH ,:; :[ I",1 FEET ) Elf:' ]'PIE TF.'.ENCFI. ,:."IF...' D, RFI:[ I'.,IF :1: EI....E:,. THE DEPTH OF FI TFi:E:i'.,IC:FI OF4: P:IIT :['.~1 THE I:) ]: ~;TF~i'.,IC:E E:E"FHEEI'.,I THE ~I...IRFFtE:E OF:' THE GI~:OUII.,ID FIi'.,l[.':, THE E:OT"i"Oi'I OF THE E;=.:;C:FIVRT~ON ,::]:1',t FEE'F::,. THEF~:EE Z:E; Ii'~O :-~;ET I,.I;[E.,TH FOR TF..'Ei',iCHIES. THE (;~[~:I'"-'I~,,,~E[.. £:,II'ZF'TH Z'.5 THE H.~:I'.,I.'[HI. jH t::.,EF'TH OF' GI:~:FI',,,'EL BETT'I.qEEI'.,I 'T'HE OUTFI=IL.L P:IF'E F:lt",ll:::, THE E',OTTOH OF THE E;:.:;L'.':Ffv'Ft.]" Z Lqi",l ,:: ]:1"4 FEET ::,. F'EF:i'l '[ 'i"; F:tPF:'L Z IZ;lahlT HFIE; THE F..:EfSF'Obi'.5 ~. E~ '[. L.. :ii T'~; 'l"O Z NF'OI;'.I"I i"H .T :i'S E:,EPRF..'"t"I"IEt'.,I'I' E:,LIR Z NG THE Z N~;'TFtLLFtT Z ON .T. N:E;F'EIi':T :[ Oi'.,l:!~, OF RN'T' 1.4ELL..~ FIE:,J'FICENT TO .]"H ]: :5 F'ROPERT'¢ FIhlF.:, ']"PIE iWL.ii'iBEF?. OF:' RE:..E;J:E.,EI',ICEE; 'l"HFl'F THE HELL. NI]ZL.L E;EII;:',/E. ..................... -'If- H.-..tl C31 ,::; ;.'.';;~: [:, %. ]]"-,.!1 ,"E:7, F" El L,'Z: -F %. K;31 ~'-,~ :~.".; IF:Il IF;;i: ~E' !~::;E,': E C~.T.!! ~....,~ :E if~:! [% E:: ...................... E~F:tC:f:::F't LL. Z lNG OF FIN'T' S'T':STEH 14 ]: Tt.-113L.IT F' I I'.,!FIL ~ N:SPEE:T I I)l'-,I laNE:, RF'F'l~:O'v'FIl._ E:'T' TH I S DEF'laRTHEh,IT !-,.1:[ LL E;E SUB..TEC.'i' TO F'F.:O:SEE. UT ]: i'i ): i",i .T. i'ILII'I 'J..OEI F'EE'T F'iii)R FI F'R:['v'WFE l.'.l[."'.:i._l... OF:: :.LSO TO ;?.00 F%ET FF.:OH Ft F'UE:LIC HELL. DEF:'EI",ID:I;t",tG i..iPOi",l THE TVF'E OF F'IJE:II_IC t,.tELII .... I'IIN.T. fqLIH E:, ]: :.'.C, TFII",tE:E F'l;:Oi'"l FI F'F.:t',,,'IaTE t,.tELL "FO F:l F'R:[',,,'FI'T'E SIEI,.IEI:~: LII",IE TO FI CEIFIhlUN.T.'I"'f E;Ei4[ER L. II",IE IS 75 F:'IIEET. t.,.IE:L.L.. LOGS FIRE F.:E6:.!LiIF.:E:D FIblD I"IU!;T E:E RE"FUII~:t',IEi:> TO THE DEPFlF.'.'TFIFZNT P.I:I:TH:I:I'.,I .3:0 E:,Fl'.r'~i; OF THE !.,.IELL CEU'"IF'LE"F 1' (:)THEIR 1"4.:E6:!I...I:[f;'.Ei'fEN.]"$ I"IF:IY' FIF'F'L..'t'. :~F'E:CZF.'[E:FtT:[Ed'.,IS FIND C:OI',I'.'.-'.';TRUCT]:E$1 E:,l'flGh~':Fli"12; F:IF.:E: F:t V Fl ]: L FE!];L.. E ]: CE:RT.i:F'T' THF:IT v4,. i~l SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -- PERCOLATION TEST PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 .... 4 5 6 7 8 9 10 11 .~42 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY: 72-008 (6/79) SLOPE DATE PERFORMED: 4u, hI Zb_,2'Z SITE PLAN ENCOUNTERED? L 'O P E IF YES, ATWHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop / 7.2(¢ .8¢ 2,','./o l/>/¢la,~ /,.~ , .~ ~;~ /o /~ I, F~d ,0<t6 DATE: 'SOILS LOG LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVI~F;~Ji~A~D~PBOTECTION ~ ~. r ANCHORAGE 825 L. Street, Anchorage, Alaska~dl T2~.z,~ , SOI LSLO~-PE~OLATIONT~T ,o , I ~ ~T E PERFORMED: 15 16 17 18 19 20 PERCOLATION TEST SLOPE SITE PLAN WAS GROUND WATER S ENCOUNTERED? ~() L -- IF YES, ATWHAT E DEPTH? Gross Net Depth to Net Reading Date Time Time ( k,"~ f~'~') Water Drop :L h "?- r~ to ,3~(, , PERCOLATION RATE ~-- '~:''~ (minutes/inch) t '/Z Z.. TEST RUN BETWEEN FT AND FT c~.¢,',~¢x,,, \~ ' " - ~,~' CERTIFIED BY: DATE: 72-008 (6/79) Box 1369, ~TAR I~OI~'TE A ANCHORAGE, .dLLASKA 9950~ 344"~?14 SIX INCH WATEr WELL DRILLED AND CASED OUT TO THE DEPTH OF DRILLED AT THE rate OF ¢,r9.~. 00 Per FOOT. LOCATION OF WELL Sits WELL LOG: O .... 7.0~ %.'u::.~,e.L ~:;.O~ 3?5 ~_,~;. COST INCLUDES ALL LABOr AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF x,~(,,9. THANK YOU VERY MUCh; Date BerNIFK-~-AUS Of RAMPART I:~ILLING WORKS ,.. C~ SERVICE Charge OF I~% PER MONTH WILL BE ASSESSED ON PAST DUE AOOOUNT~-~~ ALASKA eI1UIROFIllleFITAL COFITROL SE!RLIIC S, IFIC. ~nqineefinq $ (~nuironmenlal ,~tudies September 20, 1984 Department of Health & Environmental Protection 825 L. Street Anchorage, Alaska 99501 Dear Keith: This is in regards to the well log I am submitting for the Health Authority for Kasilo? Hllls, Block 8, Lot 15. As you can see, there is no legal on the well log. On September 20, 1984, I contacted the drlller, Bernie Claus, and asked hlm if he could check his records and verlfy that this well log was for tort.~, Blaqk._8,.gasilof Hllls. He assured me that it was, and'-~f-~ey had never drilled a we11 on any other lot for Steve and Karen Kulin, and apoloQlzed for the leQal not being on the paperwork. If you have any questions please do not hesitate to call. Sincerely, Darcy Bevens Engineering Geologist 1200 LLlesl 33rd ~uenue. Suile ~ .,~nchoreqe, /~losko 99503 ~*{907) 561-5040 'i. MI;NICIPALITY OF ANCHORAGE DEPAP, TP, tlENT OF I IEALTH ANi.) ENV!IqONM{-~Iq'i",,'~L PRO'TECTIObl Dh.,'!S',ON OF i:.NViP, ONi~AEF:FAL CERTIFICA'iLi Of INSPI-C-fION I':OR FIEALTH AU-tI~ORI rY APPROVAL OF ON-Sli [.. S[:.W[:R AFl[) WA'I El-? FACILI i-Y 264-4720 Ap,,)lication Date _ GENERAL INFORMAYiON (~) Legal Description (include IoL block, subdivision, seciion, townsl~ip, ran,qe) £-' /.) ' , ,'~-' L<' ~ ~.. ~, f::: '.L ~. ' '2 ' r ) .) ~ ,/ ..) !.. ( ... ~ ,. '._'tu~ /~i:.:: :,f~.t~L G!~.: _~'l-IL.(._. =?_ ~:. : &L._. :: ......."'-' '" '/ Location (address or directions) ,:' /~ (b) Applicant Name__ (c) Applicant is (check one): !'. (d) t_ending h]siitu~ion ._ _~ t;.?¢::~ ........... Telephone Address _~ta e (]ompany and /\gent (e) Real : ..... Address ,/i///:~L (I) Mail the HA,^, to ~.l~e following address: ,, TVPE OF RESIDF-"~,,!CE Sing!e~Family~j Multi-Family L~ Otl~er [',,lumber of Bedrooms ,% WATER SLIPPLY h~dividual Well [~_,w~' Cornmunity [] Public [~l Note: If cornmunity well system, must have \rvritten confirmation from the State Department of Environmental COlqServatioFI attesting to the legality and statu,';. 4, SEWAGE DiSPOSAl. Onsite:' PublicL] Community[il NoldingTank~ Note: If col~'lmunity well system, must have written (;oafirmetton from the State/)opartment of Environmental Conservation attesling to the legality and status. ENGINEERING FIRM PROVIDIIX~G INSPECTIONS, TESTS, FILE SEARCH, Dt~FA AND INFOR~,~ATION As ce~ tiffed by my seat affixed hereto and as of tho validation date shown below, I verify that my invesii0ation of this I-leaith Authority Apploval shows that the on-site water supply ariEl/or wastewater disposal system is safe, fenctional and adequate for the number of bedrooms and type of structure indicated herein. I further verily that based on ihe inforinaiion obtained ~ronq the Municipality el 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, ordinaiqco5, and regulations in ef ecl on the date of this inspection. Date At}proved for '!;' ) bedrooms bw Aoproved } Disapprove(l Conditional~/ Terms of Conditional Approval 'rhe Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given m paragraph ,5 above I.)y an independent professional engineer registered in the State of Alaska. Tho 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 !31-11':P do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsd)te for errors or omissioRs ip the professional engineer's work. Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MO*,/ MUNiCiPALITY OF A!I~UTHORITY APPROVAL (HAA) N 264-4720 ~*1~0~ 8 ~G Legal Descrip~/~ / ~/-/_5-' RECEIVED MUNICiPALITV OF ANCHORAGE DEPT. OF HEAl. TH & ENVIRONMENTAL Pk'O'I'ECT ON Well Classification {,&('~)/t/! ~)l~/d/L- If A B, C, D.E.C.~pproved (Y/N) Well Log Present ~/N) ____ q~tp Completed __q/~/e~ ,Yield Total Depth ~ ~) Cased to ]~2 ~0 Depth of Grouting Static Water Level ~? / ~ Pump Set At -- 2. q~ Casing Height Above Ground Electrical Wiring in Conduit ~¢~)/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test ResuRs Comments /~ Sanitary Seal on Casing ~.~N) Depression Around Wellhead (Y~ fO0 / ¢- ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot 'TesT- B. SEPTIC/HOLDING 'rANK DATA Date Installed ?/q/~.-.~ Size Standpipes ~/N) Air-tight Caps t~/N) Depression over Tank (Y,~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /'V~//'~ Separation Distances from Septic/Holding Tank: To Water-Supply Well I O0 f'7'~'- To Property Line 20 / 'TL- To Water Main/Service Line /~///~ Course t00 / '7/-- /,500 NO. of Compartments Foundation Cleanou,t ON) Date Last Pumped -! :fo, Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field ~ / ZO /''/"' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorpti_o~...Str/8~ta_ Date Installed Width of Field ~ ,-,-~- / Square Feet of Absorption Area Depression over Field (Y/~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well I (~ r-../~ To Building Foundation ~) Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field ~ /7 / Depth of Field /,~ / Gravel Bed Thickness ~,-~/ Standpipes Present ~)N) Date of Last Adequacy Test F/CC Y To Property Line ,20 7~'' To Existing or Abandoned System on ; On Adjoining Lots ,-~)/'¢' To Cutbank (if present) '/~//~ lO0/'/- 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) ~ ~/~ ~u~/Omf~:~ ~est. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that Lhav~ (zbe~ke~d,.v_e~ified,.or conformed to all M CA and HAA guidelines in Signed LI~/~~~'~ Date 7/~//~ effect on the date of this inspection. Company t¢ .~1 ~:~[~.~S I/~.C, MOA No. ,~2"'%-' O Z ¢'1~ Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) ALASKA k,,dlIgOFImEFITAL COFITIgOL SE,,JIC $, IthC. ~n§ineCrin§ f~ ~nuironmcntal $1udics KAREN ~ KULIN P.O. BOX 196577 #905 ANCHORAGE ALASKA 99519 SELLER-SAME 60327 LEGAL:KASILOF HILLS BLOCK 8 LOT 15 ADEQUACY TEST FOR SEWER SYSTEM ADEQUACY TEST DATE-JUNE 29 1986 JULY 2 1986 KAREN J KULIN P.O. BOX 196577 #905 ANCHORAGE ALASKA 99519 M~!NICIPALI~ OF ANCHORAG~ D~!PT, OF HEALTH & ENVIRONMENTAL PROTE~ION 'AU 81986 KcCEIVED THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 1139 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 750 GALLONS OF WATER PER DAY. THE SUROE CAPACITY OF THE SYSTEM IS 1167 GALLONS. BASED UPON THE TEST DATA TIlE SYSTEM IS ACCEPTABLE FOR A 5 BEDROOM HOME. SEPTIC 'rANK ADEQUACY TIlE EXISTING SEPTIC TANK VOLUME OF 1500 IS ADEQUATE FOR THIS 5 BEDROOM HOUSE. THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON JULY I 1986 . THIS REPORT DOES NOT VERIFY THE INTEGRITY OF THE PIPING FOR THE WATER SUPPLY OR WASTEWATER SYSTEM. FLOW TEST ON WELL WELL FLOW DATE-JUNE 29 1986 A FLOW TEST WAS PERFORMED ON THE WELL. 1167 GALLONS OF WATER WAS PUMPED AT A RATE OF 5.07 GPM OVER A DURATION OF 4 HOURS. THE DRAWDOWN WAS 100 ' WITH A RECOVERY TIME OF 30 MINUTES AND THE STATIC WATER LEVEL WAS 29 FEET. THE WELL IS ADEQUATE FOR THIS 5 BEDRO0M HOME. 1200 U]¢st 33rd Auenue. ~uil¢ [~oAnchoro% Aloska 99503.(907) 561-5040 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAl, IH';ALTH DEPARTMENT OF BEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTItORITY APPROVAL CERTIFICATE 1. General Information (a) Legal Descriptiou (include lot, block, Application Date__ '~--~Ax~ r~ Lc~'' lc( ,12_1r ?~-'/ subdivision, section, township, tm%ge) Location (address or directions) (b) Applicants Name 5'\-¢42.~>.!~__/<~____~_j;_~'_n Telephone - Home 5~( 61Y~;~usiness Applicants Address Fo,,.~cl~ (c) Applicant is (check one)I,ending Institution [--'-[j ; Owner/builder ~; Buyer [ffff~ ; Othe.r ~i] (explain); .... (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2..T~.e of Residence S ingle-F amily I~[~ Number of Bedrooms Multi-Family Other (describe) Individual Well..}::i: Community [:2: Public Note: If community well system~ must have ~rcitten confirmation ~rom the State Department of Enw[ronmental Conservation at'tasting to the legality and status. 4..s~y~3 D~s_a~ Note: If community well system~ must have writteu cm:irmation from the Department of Enviroumenta]. Conse~ation attesting to the legality and status. {Page 1 of 2] _En__g.ineerin~ Firm Providin_~...~.n_t~__pectionsz Tests, File Search~. Data and Information As certified by my seal Jffixed hereto and as of the validation date sho~m below, I verify that my investigation of this tlealth Authority Approval shows that the on-site water supply and/or wastewater disposal system is .,;afe~ 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 blunicipality of Anchorage files and from my investigation and. inspection, the on-site water supply and/or wastewater disposal system is in compliance ~,rith all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm Address .... (ENGINEE]i SEAL) Approved for~ bedrooms Approved ~._. Disapproved Conditional Terms of Conditional Approw~l ................................................................. CAUTION T}LE ~/NICIPALITY OF ANCIlORAGE DEPAR'[~iENT OF HEALTH ~ND ENVIRO~biENTAL PROTECTIO~ (I)HEP) ISSUES k~ALTH AUTI.i0RITY APPROVAL CERTIFICATES BASE[) SOIJgLY UPON THE llEPRESENT- ATIONS GIVEN IN P.AI[AGRAPH 5 ABOVE BY A>~ INDEPENDENT PROFF, SSIO[~kL ENGINEF, R REGISTERF~O IN THE STATE OF kJ, ASKAo 'file DHEP DOES THIS AS A COURIESY TO PURCHASERS OF HOMES 'AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE= MENTS. Eb[PLOYEES OF DHEP DO NOT CONDUCT INSPEC'flONS OR ANALYZE DATA BF, FORE A CERTIFICATE IS ISSUk[ ,, THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSI~LE FOR ERRORS OR OMISSIONS IN THE PROFESS!O~XhiL ENGtNF, ER'S WOR. K. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-1 9-84 WELL DATA Well Classification Well Log P~esent (Y/N) Total Depth ~h~o Cased to Static Water Level d~+ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) If A, B, c~ C, D.E.C. Approved(Y/N) Date Completed ~fp'~ ~S/Z?3 Yield ~ (PP~ ~k & ~ ~pth of G~outin~. ~ ~ Sanit~,y ~al on Casing (~)~ . ~ession ~ound ~l~ead .(,X~) 1W Pump Set At Separation Distances from Well: To Septic/Holding Tank on Lot 1%~ 6y px~"~~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot I[7 ~?~ Adjoining Lots To Nearest Public Sew~=~ Line ff$~c To Nearest Public ~ Clean, t/MaXcie ~ ~ , To ~est ~ ~vi~ Li~ on ~t Wate~ S~le Collected By ~ ~ ~ ; ~to ~p '~ I ~ Wato~ S~le Test ~sults ~s ~ B. SEPTIC/HOLDING TANK DATA Date Installed ~f_pr ~ / 72~ Size I ~oo No. of C~a~tm~nts ~ Standpipes .(.Y/N) J Air-tight Caps (Y~) y Foundation Cleanout (Y~) ~ ~p~ession ove~ Ta~ (Y~) ~ ~te ~st P~d ~ ~ P~ing~aintenan~ Con~a~ on File (Y~) ~ ; fo~ ~ Holding Ta~ High-Wate~ Ala~ (Y~) ~ ~%~a~y Holdi~ Tank Pe~t (Y~1) ~ Sep~ation Distan~s ~ ~ptic~old~g Tank: To Water-Supply ~11 I% 6 ~l ~1~'~ To ~ilding Foundation 2~ To ~o~ty Li~ ~ I,'~ TO Dis~sal F~eld ~ To ~ter Main/~vi~i~ ~ To S~e~, Pond, ~e, ~ ~jor ~aina~ Co~ ' ~ [ O O ~ Counts [Page 'l'of 2] 2-15~84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequacy Test ,[~;/L Type of System Design · Length of Field ~ c/- Depth of Field { '~ Gravel Bed Thickness '~' ~ Date of Last Adequacy Test To Water-Supply W~ll To Building Foundation Lot gAk- To Water Main/Service Line To Stream/Pond/Lake/ca: Majo~ D~ainage Course ~ 10o '+ TO D~iveway, Parking Area, ca? Vehicle Sto~age Area t 5 Separation Distance from Absorption Field: To lhzoperty Line IN ~_ ~rz_. TO Existing or Abandoned System on ; On Adjoining Lots ~vlA- ~7~ To Cutbank(if present) A~ Comments nxrr Date Installed Size in Gallons /Manhole/Access (Y/N) "Pump on" Level at High Water Alarm Level at Tested fop Electrical Codes(Y/N) / Coa~t~nts "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA ** Check Permitted Bedroom RatingA~ainst HAA Request I certify that I have checked, verified, or conforrc~d to all MOA HAA Guide2 on the date of this inspection. Signed ~~ ~~--~ Date ~P /~ /~ Company /~ ~c~ ~ /~¢. MOA NO. KB1/d5/s [Page 2 of 2] 2-15-84