HomeMy WebLinkAboutMEADOW RIDGE ESTATES NORTH ADD BLK 6 LT 6AMeadow Ridge
Estates North
Addition
Block 6
Lot 6A
#051-531-30
_ - 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
II / � ,�
L /`S �-C� Y�.4� I _
PHHONE(� (J
lL.t XU Q.
NEW
❑UPGRADE
MAILING
ADDR ES
LEGAL DESCRIPTION
LOCATION ,g-
NO. OF BEDROOMS
U
DISTANCE TO:
Well r
t �,�'jU
Absorption are
�
Dwelling
6
PERMIT NO.
yi
w2
~
Manufacturer Cy ✓�('
Materia �_I
No. of compartments
�'
rn
Uq. cap cj.f e Ilons
(�
IF HOMEMADE:
Inside length
Width
Liquid depth
O
Jaz
DISTANCE TO:
Well
Dwelling
PERMIT NO,
f'
U Z Q
S-F
Manuf rer ate
_
rapac' ons
O
w=
DISTANCE TO:
Well
Foundation r Nearest lot line r
`70 tt
PERMIT NO. /..-
J LL z
Z W
_
No. of lines
�/ �/_ _
Length of each li `
_
Total length of li es Trench widt
� S inches
Distance between lines
x
< F
o
Top of the to finish grade i
-
Material beneath tile
'sem
Total e fective abso9ti n a
Wig;
w
Length
Width
Depth
PERMIT NO.
Q H
aa
Type of cr
Crib eter
Cri tha
eff tive absor
rea -
WWell
N
- DISTANCE TO:
Building f tion
Near of line
J
J
Class0
Depth
Driller
Distance to lot line
PERMIT NO.
W
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area (s)
OTHER
PIPE MATERIALS
303 '�c��r
SOILTESTRATING
r
INSTAL4ER �.-
� « n
4'
REMARKS
APPROVED DATE LEGAL
79_nt3 IRK, 317RI / /
�U P 1 1 Q 1 401LX Q- 1, 13 F;:!r. .1q F::I� �qm�::::q VIA H�
DEPHRTMENT i HEHLTH HND EAS IRONMENTH1 OTECTION
825 'L' STREET, HNCHORHGE/ HK. 99501
264�4720
PERMIT NO ( G11175 )
HPPLICHNT STEVEN L SKHGGS CONST
LOCHTION PIE: CREEK
LEGHL L6B6 MEHDOWRIDGE
PO BOX D CIA UGIHK
/ / '1\-
11-11-0
\_
/ �/
/
]�^
_
688-28 ��
LOT SI2!E FI :ET~
TYPE C"IF SOIL HBSOrn!PTION SYSTEM TRENCH
MHXIMUM NUMBER OF BEDROOMS � ] SOIL RHTING (SQ FT/BR)� 116
THE REIT! UIFO ED SIZE OF THE SOIL HBSCOO PTION SYSTEM IS:
�IEEE
W 1-1 --
-": i ( ..... ��KIAlF-
H — W Q Koo IT: Fol two EFE L.. Ell FEE �-v Ib. -H ��;;
THE
LENGTH
DIMENSION IS
THE LENGTH (IN FEET) OF THE TRENCH OR NFIELD�
THE
DEPTH
OF H 71SNCIA
OR P11- 15 THE SURFHCf.-: OF THE
GROUND
HND
THE BOTTOM
OF THE EXCHVHTION (IN FEET)
THERE IS NO
SET WIDTH
FOR TRENCHES
THE
C,�RHVEL
DEPTH IS THE:
MINIMUM DEPTH OF GRHVEL BETWEEN THE OUTFHLL PIPE
HND
THE BOTTOM
OF
(IN FEET).
Q FEE W
U X IF" ���J:
0- F11 INJ H< A", 1: M FEE ��P.`.,��p KI:); t.. P.
PERMIT HPPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE
INSTHLL�TION INSPECTIONS CF HP -4Y WELL'S PF-!OPERTY HND III[.--
.. ........
HE
_� Wj Q �'.::q 1: 11".4 E.:- 1 1: 0 r -A "'El. F-9 F�'.�' F�;!! EE L-9 REE:: ��....
BHCKFILLING OF HNY S9STEM NITHOUT FINHL INSPECTION HNC, HPPROVHL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSECUTION
MINIMUM DISTHNCE BETWEEN H WELL HND HNY ON-SITE SEWHGE DISPOSHL SYSTEM IS
100 FEET FOR H PRIVHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTHNC� FROM H PP!IYHTE WELL TO H PRIvHTE SEWER LIrdi IS 25 FIET HND
TO H COMUNITY SEWER LINE IS 75 FEET.
OTH�R REQUIREM�NTS Mf"Y HPPLY. SPECIFICHTIONS HND CON�TRUCT�ON DIHGRHMS HRE
HVHILHBLE TO INSURE PROPER INSTHLLHTION.
E:E:: Pel 1: 11- 1 F,.!: E-E� U".::v FEZ IC -7 Q P1 W 101 W it: :1-/
I CERTIFY THHT
1� I HM FHMILIHR WITH THE FOR ON-SITE SBWERS HND WELLS HS SET
FORTH BY
YPIE MMMINWITY OF HNCHORHGE
2� CE WITH THE CODES
]� SITI SEWER SYsTEM MHY REQUIRE F-NLHRGEMENT IF THE
RES INCLUDE MORE THHN7 077
] BEDROOMS
SIGNEDNT ~~~~^-.~
' HPPLICH_ �I�VEN L SKHGGS CONST
v�
`
ISSUED BY_ _ ^...... .... DHTE~^
O & E ENC.,.NEERING & DEVELO, MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster Earl Ellis
694-2774 SOIL LOG 688-2280
Performed for: Name: kQ�G �� r"J`-�'�«�" '�� Tel. No���'
Mailing AddressL J
Legal Description: L' L4' � � �c•�(f��_ �P f �r1 7e "+ ) .y .=-
Depth (feet) Soil Characteristics
0
2
3
/1%N,JuI
4 �)
5 A,
7
a i/cL•�y.�L�
9
10
11
12
13
14
15
16
^n
PLOT PLAN
PERC.TEST
Ground Water Encountered: Yes No 41� If yes, what depth
Proposed Installation: Seepag� Pit n Drain Field L�
C:nmmwnTc• 110,./�
Performed by:
PLOT PLAN
PERC.TEST
Ground Water Encountered: Yes No 41� If yes, what depth
Proposed Installation: Seepag� Pit n Drain Field L�
C:nmmwnTc• 110,./�
Performed by:
December 29, 1975
#780400
Joseph Dickman
3307 Boniface Parkway
Anchorage, Alaska 99504
Subject: Lot 6 Block 6 Meadow Ridge Estates Subdivision
A permit issued by this department for well and/or
sewer system has expired.
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 there are any further questions, please contact
this office at 264-4720.
Sincerely,
Les N. Buchholz, R.S.
Senior Environmental Specialist
um/ljw
enc: copy of permit
,--j it r4 A Ll L w__ " I L I -lir lk-5 F- F""I I "q a-. r__l 55 F-1 w � ...A �_
DEPARTMENT ( HEALTH AND ENVIRONMENTAL r__`OTECTION A/0
825 'L STREET, ANCHORAGE, AK. 99.-,,l
264-4720
ID N—; I -r I -E Sc-,
PERMIT NO. 780400 )
APPLICANT JOSEPH DICKMAN 3307 HON IFACIE 337-2181
LOCATION HOMESTEAD ROAD
LEGAL L6 86 MEADOW RIDGE ESTATES LOT SIZE 21351 SQUARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SO FTZBR)= 200
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
Loos=F-r"— :B L_Er_r4l3-r"== W-5-7 13F-tCf=-1VE-=L_ E:
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF 8 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).
FRF=C4UlFccff=r_:a "rFV"K "=-laE:— 1;2!510 0"lL_L_0"S-
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.
--- -rWC) < :2, > I No---F:lmE:j0-T I ON53 "FR F= FRF=C4U X FR!l_=0 - - -
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.
OTHER REQUIREMENTS MAY APPLY, SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F="F-=RM I _r F=Xfz" I FRe:E; L� a IZ- e M 0 e F;:.* :3:1L _- �L!9 71 CE4
I CERTIFY THAT
1: 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: 1 UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE 19 REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
5 1 G N E D ---------------
APPLICANT JOSEPH DICKMAN
ISSUED BY.10Z --- ------- ---DATE__
V 3. 2
201
m
1 4 ,
'If C, 11 1) �) 111"
asro LexIf
I
&6,2S4
. .... ... ...
I—.- -oL
If f4..
foo,"o'
of
If.
If Of
of fo I, f o
Municipality of Anchorage
On -Site Water & Wastewater Program "
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I. D. 051-531-30 Expiration Date:
1. GENERAL INFORMATION
Complete legal description MEADOW RIDGE ESTATES NORTH; ADDITION; BLOCK 6, LOT 6A
Location (site address)
Current Property owner(s)
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
25033 HOMESTEAD; CHUGIAK, *AK 99567
JAY & SHANNON CASEY Day phone C/0 AGENT
25033 HOMESTEAD; CHUGIAK, *AK 99567
JOHN WAGNER Day phone
Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
360-4884
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
E
Individual Water Storage
❑
Individual Holding tank
❑
Community Class A Well
Community On-site
❑
Public Water System
❑
Public Sewer
❑
i�
L,
t/
Received by '' ' '- I 1.
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 1/40
Date of Payment
Receipt Number CJ4LI 69
COSA # Cfj21 X06
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
Q
As certified by my seal affixed hereto and as of the validation date shown below, / verify that my
investigation, based on procedures outlined in the Certificate of On -Site Systems 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. l 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
and State codes, ordinances, and regulations in effect at the time of installation.
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, Lt D, 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.
System #1 Approved for
System #2 Approved for
Conditional approval for
Phone
337-6179
Date f I ! t3
Original Certificate Date: IaS�
ba,nicipality or Anchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTCHMENTS:
COSA Checklist Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
rae� ivne�
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: MEADOW RIDGE ESTATES NORTH ADDITION; BLOCK 6, LOT 6A Parcel ID: 051-531-30
A. WELL DATA
Well type A
Date completed
Total depth ft.
PUBLIC WATER
If A, B, or C provide PWSID# 211431 Well Log (YIN)
Sanitary seal (Y/N)
Cased to ft.
FROM WELL LOG
Wires properly protected (YIN)
Casing height (abo round) in.
AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESU .
Coliform colonies/100 ml. Nitrate mg./L. Collected by:
A c: ug./L. Date of sample:
B. SEPTIC/HOLDING TANK DATA *LOCATED IN CRAWLSPACE
Tank Type/Material SEPTIC/STEEL Date installed 11/13/81
Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) YES
Foundation cleanout (YIN) *YES Depression over tank (YIN) NO High water alarm (YIN) N/A
Date of pumping 3 PumperCu*l Qwt �s k
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE TO BOTTOM OF SUMP
Date installed 11/13/81 Soil rating (g.p.d./WorCbdrm 11166 System type TRENCH
Length 35 ft. Width 3 ft. Gravel below pipe 5 ft.
Total depth *5.66 ft. Eff. absorption area 350 ft' Monitoring tube *ES Depression over field NO
Date of adequacy test 11/6/13 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test **0.5 in. Water added 690 gal. New depth***9.5 in.
Elapsed Time: 994 min. Final fluid depth 9 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE If yes, give date —
**21.5" BELOW INVERT. ***12.5" BELOW INVERT.
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
"Pump on" level at in. "Pump off" level High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on
Public sewer main
Sewer /septic service line
On adjacent
On adjacent lots
manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
i
Building foundation `* 15 Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+__
Wells on adjacent lots 100'+PVT/200'+PUBLIC
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO
Property line
Building foundation 10'+ Water
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 3'
Curtain drain NONE KNOWN Wells on adjacent Iots100'+PVT/200'+PUBLIC
F. COMMENTS
* A egU4-t.,
f oN r
�J CF- -ra>
t o� ,-��v rl urfk�"ownl,
Aw+i a -P ro
�G �.
SFS qi-Q ,�
5uave-y
G. ENGINEER'S CERTIFICATION
1 certify that t have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date H6 63
(Rev. 11105)
J fr lk._G9Aess.-
CE -795.3 m�
I.1. 1.Y. 13��AoG
AAGPCSB M91FD RMI
DUN. (AISAYe)
fV
N89° 55' 20"W 131.00'
rA0PO4a BIMIIa C(MIIER
iNMwa dI110LT
E�Ni Blldll' SER•Of
NGL II I 9:18A04
K.w IIu•nNc gTeALx
GARAGE
1l q, N
N
N
2
0
5
c 0 16.q,
EXISTING
HOUSE
$ ?0,0, 1
0 7A
b
A tr
r
h
�
10' UTIL ESMT -`-�--
L=10226' R_ ..
-330.00.....
_a....,.
..-
m HpMESTEAO
RpAD
UNDER NO CIRCUMSTANCES SHOULD AN AS-BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE UNES.
THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY
AND ASSUMES FINANCIAL UABIUTY ONLY FOR THE COST OF THE SURVEY.
LISTED DISTANCES PREVAIL OVER SCAUNG. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
LJ LCT SURVEY SURVEY TYPE
SYMBOLS
❑ FCUNDATICN AS-BUILT
SET REBARO ASPHALT
ElFINAL STRUCTURE AS-BUILT
❑ TCPCCRAPMY
s.c :::
O FOUND REBAR .G 9 9 WOOD FENS -- CONCRETE
PLOT PLAN ... AS-BULLY ...LOT SUR4E'r ...
00 ASSUMED ELEV. T--TF METAL FENCE ® WOOD DECK
AS-BUILT ... ND CORNERS gT RECERTIFN:ATICN AS-BUILT ... NO CORNERS T
PLOT PLANS & LOT SURVEYS
NOTE:
IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO
ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
CONSTRUCTION. TO VERIFY PROPOSED BUILDING GRADE RELATIVE
SHOWN. FENCES, WELLS. SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS.
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE
ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION. ONLY. SNOW
THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS
MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT.
ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
SURVEY CERTIFICATION
•••,��efrr,,
.-o......
Prepared by
Robert E. Johns, Jr. & Assoc.
PLOT PLAN
mw �rw-w�
Y• bt Yew, s,L i•u6tl M1w•u,. ak eot I
���P;�j
•• ��
Professional Land Surveyors
Professional
eeM AUN s MdIYn•a a m m• w• ewnw•
e ,.w.n en w ww m w. em a wr
•�q
,
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1700 Brink Drive.
ANCHORAGE. ALASKA 99504
•Iwo
swaw �La ann+me Iw+ e.n
FOUNDATION AS-BUILT
^� 1• •:•,
t 4 h :• f'
�. ehp.: .wfi:, .,
Scale: ,I — I
1 — 40
Rec. Lot S.F.
Rec. Plat File Na
Vote Surveyed:
11/13/13
Drawn by.
REJ
Checked by.M
JJ
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rwneeNwax Ne me nm a a.
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-- RpBERT E. J S, JR ,�' �
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Grid:
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Vote Drown:
11/13/13
NW1462
13-589
FINAL STRUCTURE AS-BUILT
4121—S : •°,e��
II �° ••,•
Le9ol Description:
I. Ieewl L Aae+ a. Iw+r ...alr awe
•Ie' °�
. . •''• ci��1�
q ea ...........
Lot 6A Block 6
A 6V• aM M wWO0aM11• wi•1 MIM
A �a�a•..
i�„�;••••
MEADOW RIDGE ESTATES NORTH
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
7C7
A Z
--
3.... TYPE OF WATER SUPPLY:
`'
Individual well
--
�,'•
Community well XXX
r -n
r^r n
',
:,.. ...
i'^ = il
Public water
4�
r
.... ..:.,.....
..- - ... .r -
.,
.. _ ..-- - ...:.
.-.. s.. „yam
!ate.
... _ ._
attesting to the legality and status'of system.
72-025 (Rev. 1/91) Front MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: dr (oA 15Lt4-_ to tkp v �19*arcel I.D. O 5,1 - S 1 I , 3 0
A. Well Data n
Well type A If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump levell
Date completed Driller
Cased to
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
WATER SAMPLE R56ULTS:
�k
Coliform / Nitrate
of sample:
B. SEPTIC/hfehONG-TANK DATA
Casing height
Wires properly protected (Y/N)
ri%AuTL&i7X03111[a]►1
On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Collected by:
Other bacteria
Date installed � 1 b t Tank size \ C*oa Compartments 2
Cleanouts N) Foundation cleanout(jjN) J Depression II(M .,
High water alarm (Y;� Alarm tested (Y/N) A� ,
Date of pumping 1C> -0 -`t 4 Pumper S� Li-r-SCoa L-
LoL �r� < <' G I S a an-ry
SEPARATION DIS ANCES FROM SEPTIC/hl4L9W4GTANK TO:
Well(s) on lot 4 On adjacent lots ZOo k
To property line Lo t t -
Surface water/drainage _
72-026 (3/93)" Front
Absorption field
kk
Foundation 5 t
Water main/service line Ink
CONTINUED ON BACK PAGE
m
�3
O Z
fi7
J:
v
�
m
Z
w.w
C,N
in C
rn T
rnZ
C -"m
2
C
y C
O `r
Public sewer manhole/cleanout
Petroleum tank
Collected by:
Other bacteria
Date installed � 1 b t Tank size \ C*oa Compartments 2
Cleanouts N) Foundation cleanout(jjN) J Depression II(M .,
High water alarm (Y;� Alarm tested (Y/N) A� ,
Date of pumping 1C> -0 -`t 4 Pumper S� Li-r-SCoa L-
LoL �r� < <' G I S a an-ry
SEPARATION DIS ANCES FROM SEPTIC/hl4L9W4GTANK TO:
Well(s) on lot 4 On adjacent lots ZOo k
To property line Lo t t -
Surface water/drainage _
72-026 (3/93)" Front
Absorption field
kk
Foundation 5 t
Water main/service line Ink
CONTINUED ON BACK PAGE
-
DATE`.iECEIVED
INSPECTION APPOINTMENTS
TIME
TIME
TIME
DATE
DATE
DATE
INSPECTOR
INSPECTOR
INSPECTOR
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTII?OT. OF HEALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION
•
ENVIRONMENTAL SANITATION DIVISION NOV `� C j�1
Telephone 264.4720
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REQUEST FOR APPROVAL OF INDIVIDUAL WA D S'i`l�6OCfL% V_IEID5
* ATTACH WELL LOG. A well log is required for all wells drilled
DIRECTIONS: Corr pi`ete all parts on page 1. Incomplete requests will not be processed. Please allow ten'O ) days for processing.
1. PERTy WNER
PHONE
• � I � J
rZi1//7l�
NG ADDRESS
596 n C/ 45-0
PROPER Y RESIDENT (If different from above)
PHONE
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
2. BUYER - s
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS -
4. REALTOR/AGENT
PHONE
MAI LING ADDRESS
5. LEGAL DESCRIPTION
/
w
STREET LOCATION
6. TYPE OF RESIDENCE
NUMBER OFrBEDROOMS
L4— SINGLE FAMILY
❑ One ❑ Four ❑ Other
Es_�_`Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SUPPLY
❑ INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
&J -"COMMUNITY
since June 1975. For wells drilled prior to that date, give well
PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
5:>SP�INDIVIDUAL/ON-SITE**
d!� YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/74)