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HomeMy WebLinkAboutMCKINLEY VIEW ESTATES BLK 2 LT 1McKinley View Block 2 Lot 1 #051-792 05 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 rPRONE LOCATION DISTANCE TO', Manufacturer iF HOMEMADE: Liq. DISTANCE TO: Manufacturer T Well DISTANCE 'TO: Top of tile to finish grade Absorption ar e,~. Width Inside length Dwelling JMaterial ~ot kine Type of crib DISTANCE TO: DISTANCE TO: Crib diameter Foundation Total length of lines Material beneath tile Crib deptA Buildin~ tmdat~ ~. Driller Sewer kine NO, OF BEDR~;~OMS Liquid depth PERMIT NO. Liquid capacity in gallons PERIV~IT NO, Distance between lines inches Total effective absorption area inches Total effective absorption Nearest lot Iine/~ Distance to lot line TPERM!T NO. Septic tank OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER ~- ~ REMARKS 72-013 (Rev. 3/78) DATI DEPFIRI"MENT' 0 -tEFILTH FINE:, ENVIt;'.ONMEtq]"RL f ?rECTION 825 "L' S"FREET., RNC:HORRGE., F:IK. S~95b,1. 264-4720 EZ~ P...Ii .-- ES; % T' EE :% E;FZ i~41 i?',Z F;~.: Fr.'' ~E !R:~.". ll"'dl ][ 'T' FIF:'F'L I C:FlhtT B I L.L. C'ROtjSE L.OCFtT l ON CE':NT LIP:: I UN XS & S ENGII"~EERING SRB :i. 96X E ~S94.'-29729 L. EGt::tI.. L ::!. B 2 MCKINLEY VIEW ESTFtTE'S LOT SIZE TY'F'E OF ,.__ ,_, ,,;: ..=-,.. . ..... ., ~., . . bt~::~4 :,. I1_ ~'~ESORF"TI3f"~. :,¥_,]Lil IS 25000 SQL.II-3RE FEET i'iF:I;:.~iIMUM NUIflBER OF BEDROOMS := Z-: SOIL. RFI'T'ING ,:.'SQ FT/BR):= :i. 00 THE F..:EQU!REt.') SI2:E OF THE SOIL FIBSORPTION SYSTEM IS: THE LENGTH DIMENSIOt'-,f IS THE LENGTH (Ihl FEE]") OF THE TRENCH OR DRFIINFIELD. THE D, EF'TH OF Ft TF.:ENCH OR PiT IS THE E:,ISTflNCE E~ETt.,.IEEN THE 2I!R'FflCE OF THE tSROJt'.,I[', FIND THE BOTTOM OF' THE E,--,UP,,I-ft.t',l ,:;it'-,! t::'EET;:,.t~,, i ! '--~., THE GRRVEL DEPTH IS THE MINIHUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL F:'IPE FIND THE BO'T'TOM OF THE EY, CFfVRTION ,:; IN FEET.':,. PERMIT' FIF'F'LICFII'4T HFIS THE RESPONSIBILI'T'V TO INFORM THIS DEPFIRTMENT' DLtRI'NG THE INSTFtLLFFI"ION INSF'ECTIONS OF' RN'¢ WELLS FtDJFICEI'.,IT TO THI:S F'ROPERT'¢ FIND THE NUMBER OF RESIDENCES 'T'HR'T THE WELL 1.4ILL SERVE. f3RCKF:'ILLIHG OF RN'Y SYSTEM HITHOUT FTNRL INSPECTION FIND RPPP::O'v'RL B'¢ THIS DEPRRTMENT I.,.iILL BE SLIB.~EC:T TO PROSECUTION. MINiPtLIM DIS'f'RNE:E E:ETWEEN FI WELL. RND FINh.' ON-.SITE SEWFIGE DISPOSRL. S¥ST'EM IS :1.00 FEE'T' I;'.:'OR I;I F'RIVFITE WELL OR :1.50 TO 200 FEET FROM Ft PUE:I_IC WELL DEPENDII'.,IG LIF'Ot'.,t THE T"r'PE OF PUBLIC I.,.IELLo HINIML.tM DiSTRNCE FROM Fl PRIVRTE t.4ELL. TO R PRIVFi"I-E SEHER LINE IS 25 FEET RhfD TO R COMMLINIT'T' SEWER L. INE tE; 75 FEET. WELL LOGS FIRE REC.:!UZRED FIND MLbS;T E:E RETUI;..':NED TO THE DEF'FIt:;~:ThiE:.NT HITHIN Z::E:I D, FI'.¢S OF' THE WELL COMPI_ETTOhl. OTHER REQUIREMENTS MFPr' FIPPL"r'. SPECIFICFITIONS FIND CONSTRUCTIOiq D, IFtGRFIMS RRE FtVF:IZLRBL. E TO INSURE PROPER INSTFILLFITTCd'-,I. I CERT I F:'¢ 'T'HR"I" i: i Rt;-I FF~MILII::IR WITH THE i~:EQUIREMEI'.4TS FOR Ot'.,1-.SI'TE SEHEF.:S FiND 14EL.I.,,,S Fl'.-".:; SE]" FORTH E:"P THE Mi. JNICIF'FiLITY OF ~NCHORFIGE. 2: t WILL INSTRLL THE SYSTEM IN F:ICCORF)FINCE 14ITH THE CODES. 3:: t UND, EF*::STF:tt'.,ID I"HFIT 'T'HE ON-SiTE SEHER SYSTEM I"IR'T' REQUIRE Et",tLRRGEMENT IF: 'THE Iq'.ES I[:'ENCE IS REI'"IOD.4E%E;~ IN,.]:LUD, E' MORE THF-Ii",I ]: ErEDR,:]OI"IS. F:IPFLIC.=INT BILL CR'.OUSE L~0-4~%_- D¢¢x,~,~¢,~) ",~ L ~ .r-~ ~ ......... ......... ............................................. r.., ri ............................................... .... F'ERMIT NO. ,' oe.:t.~:a,: .... ', RPF'L I CRNT BILL 3R'3L SE L. OCRT [ ON .... :.~,c ENGINEERING _,RS LEGRL Lt~B2 MCKINLE'¢ VIEP.I E=,TFllE:, LOT SIZE TVF'E OF ':;nil F~E:SOF:F'TION S'¢STEM IS: ~zF~ j~...~t~,~ :9'£¢?S'.9'S¢ SQURF::E FEET' I','IRXIML~M M i',1EER Elf BEE:,ROOMS = SOII_ F.:FIT I NG ]"HE REQLIIF::ED SIZE OF TFtE SOIL RBSORP"rlON =~,=TEM IS: E:) tE F:" T' Fit ~= 4- L_ EE: Pql G -ir' It4 .== .¢-=¢ ..:, F:.= R "~- ES. L £:. E F" T' f'~ == THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH Of;..' DRRINFIELD. THE DEPTN OF' R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SI, JRFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVFiTION (IN FEET). THE GRRVEL. DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE Bo'FrOM OF 'rile E::.:',CRVRTION (IN FEET). " '1 l-'- ' ' "'- 'FI '- ' PEF.:HIT HF[._I...HN7 HRS THE F'.E:,F_Nz,!E, ILTTr TO ]NFOF.:M THIS C, EPRR'T'MENT I}t.IRZNEi 'f'l-~E INSTFILI_FtTION IHSF'ECTICNS OF FIN"r' WELLS RE:,JRCEI"~T TO THIS PROPERT? FINE:' THE -' "--" r'~ '"' ':' . NIJME:ER OF= F..E:,I_.ENUE .... THFIT TNE WEL.L PJILL SERVE. RCI<F:'IL..L. INU OF RN"r' =,r.=TEII I,.IITt-IOUT FINRL INx, FE~.TION RND RPPRZVRL B"r' TNIS [:'EPFIRTMENT WILL BE SUBJEC:T TO PF.':SE:_TION. MINIMtJM DISTANCE BETWEEN R NEL. L. RND RNY ON-SITE SEWRGE DISPOS;RL. SVSTEM IS :L(1Cl FEET FOR R PRIVRTE t,.IELL OR 15El TO 2C18 FEET' FROM R PUBL. IC: WELL DEPENDING UPON THE T'¢PE OF PUBLIC WELL. MINIMUM [:'ISTRNCE FROM R PRIVRTE NELL TO R PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNZT'¢ SEWER LINE IS 75 FEET. I.,.tELL LOGS RRE REQUIRED RND MUST BE RETURNEE:' TO THE DEPRRTMENT WITNIN SCi DR'CS OF THE 1.4ELL COMPLETION. OTHER REQUIREMENTS f'lFt'~' RPPL'¢. SPECIFICRTIONS RND CONSTRUCTION DtRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. I CERTIF? THRT l: I BM FF4MILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND 14ELLS RS SET FORTH B'¢ THE MUNICIPRLI'T¥ OF RNCF!ORRGE. 2: I NIL. L INSTFiLL THE S'¢STEM IN RCCORDRNCE 14ITH TFIE CODES. ]:: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MR"r' REQUIRE ENL. RRGEMENT IF TFIE RESIDENCE IS REMO[:'ELE[:' TO INCLUDE MORE THRN ~: BEDROOMS. RLJssell Oyster 694-2774 Performed for: O & E ENG~.,IEERING & DEVELOI- ,'/lENT CO. Legal Description:. Name: Mailing Address: Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 SOIL LOG Tel. No. Earl Ellis 688:~280 Depth (feet) 0__ 10__ 12__ Soil Characteristics Ground Water Encountered: Yes.__ Proposed Installation: Seepage Pit Comments: · No If yes, what depth Drain Field PLOT PLAN PERC. TEST Performed by: Date:. Municipality of Anchorage Development Services Department . Building Safety Division ... On-Site Water & Wastewater Program ...... ' 4700 South Bragaw SL . . P.O. Box 196650 A~chorage. AK 99519-6650 www.d.anchorage.ak.us (907) 343-79O4 CERTIFICATE OF HEALTH AUTHORITY. APPROVAL FOR SINGLE FAHILY DWELL'lNG '" '- GENERAL INFORMATION Complete legal description Expiration Date:' '~5"-'- .,~ ~'-- '~),-'~- LOT 1~ B~.OCK 2 MCKINLEY ViEW ESTATES SUBDIVISION Location (site address or directions) 22415 CENTURION. DRNE * CHUCIAK, ALASKA 99567 Current Property owner(s) BOB RICHARD Day phone 688-9760 Mailing address Lending agency 22415 CENTURION DRNE * CHUGIAK, AK 99567 Dayphone ..' Mailing address Real Estate Agent Day phone Mailing address Unless otherwise requested, HAA will be held by DSD for plckup. 2, NUMBEROF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class A Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-slta Individua! Holding tank The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (FIAA) based only upon the representations given In paragraph 5 by an Independent professional civil engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer of titJe (except between spouses) for properties sewed by a single family on-slte wastewator 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 sample results less than 30 days old. (Certificates may be reissued for a per~od 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. 'i'he Municipality cf Anchorage Is not responsible for errors or emlsslons In the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal a~fixed hereto and a~ 'of the vaiida ~on date shown below, I ve#[y that rny Investigation, based on proc~dures o(Jtiined in the Health Authority Approval Guidelines for this application, , shows that the on-site water supp~ and/or Wastewatar disposal system Is(are) safe, functional and adequate for the number of bedrooms and ~3e of structure Indicated herein. I further verify that based on the Information obtained from the Municipality of Anchorage files and from my lnvestigatton and Inspection, the ,. on-site water supp~; and/or wastewater disposal system Is(are) In compliance ~th afl applicable Municipal and State codes, ordinances, ?d regulations In effect at the ~m, e of In.s~llation. Name of Firm ALASKA WATER &: WASTE'WATER CONSULTANTS. INC. Address 690'l'""DEBARR ROAD. SUITE 2B * ANCHOP,~GE. AK 99504 Engineers Printed Name JEFFREY A. CARNESS, P.E. Engineer's Comments: In conducting this evaluation, AWWC, Inc. a~tempted to provide e thonx~gh, conscisn#ous engineering ana~ls of ~he system In acceMance ~ ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the lfme o! the test. and separaffon distances measured to madly' Identifiable features. The operational life of a~l we/Is and septic systems depend on the local soils condition, groundwater levels that may fluctuate dudng the year, and the water usage of the family belng served by the system. These conditions are outside the cen~ol Of the evaluater of the system..Satisfactory test ' results do not guarantee fu~ra perfon'nance of the system, nor do they guarantee that there are no hidden defects or anctcechmants. AWWCo Inc. can therefore not pro~fde any watrenty or future estimate ofhow long tho system will continue to meet the operational requirements of the ADEC or MOA DSD. The contest of this report Is for the sole benefit of the owner listed above. Anyreliance upon or use of this repo~t by other pereo_n or pan'y Is not author':ed, nor v/lilt confer any legal dght wflatseaver. DSD SIGNATURE /"/ Approved for '~ bedrooms. Disapproved. Conditional approval for Phone 357-6179 Date Attachments: I.-IAA Checldist Manitenance Agreements Septic System Advisory Supplemental Engineer's Reort Well Flow Advlsory Other Municipality of Anchorage Development Services Department O~,-Slte Water & Wa~ewater I~ 4700 ~OUlh Bragaw ~ P.O. B~x 196650 Anchorage, AK g951g-6650 HEALTH AUTHORITY APPROVAL CHECKLIST Legal DescdpUon: LOT 1~ BLOCK 2 MCKINLEY VIEW EST. S/D Pamel ID: A. WELL DATA 051-792-05 WelltyPe ct~ss 'A' IfA, B, orCprovldePWSlD#. 210697 Welll.~g(Y/N) completed Sanltmy ~ (Y/N) Wires prope~3mle~/N) Total deplh ft. Cased to~ ~ height (above ground) FROM AT INSPECTION Date of test Steli~ ~..,'''''''''''''/ It. It. ~rnduclion g.p.m, g.p.m. WATER SAMPLE RESULTS: e. SEPTIC/HOLDING TANK DATA Tank Type/Material GREER/STEEL Tank~ze 100o gal. Number of Comparlments 2 Date Inste~nd 2/1985 Qeanou~ (Y/N) YES Foundafiendeanout(Y/N)YES DeptesMonovertenk(Y/N) NO Dateofpumping 4/24/2001 Pumper C. ABSORPTION FIELDDATA ~ Dateinsteffed 2/1983 Leng~ 20 ~ H~h water alarm (Y/N) dR's PUMPING sea mung (g.p.d.m'~ lOO'+ ~ 24 ft. System bpe BED Gravel below plbe 1 It* Total depth *5.5 It. Eft. al~orptlon area 480'+ fi' Monltming tube YES Oate of adequacy test 4/25/2001 Results(Pass/Fall) PASS Ruld deplh In absorption field before test 0 In. Water added 668 gal. Elapsed Time: 112 mln, Final fluid depth 0 In. Absoq~on rate Any reJuvenafien treatment (past 12 mo.) (Y/N & type) NONE KNOWN N/A Depression over field NO For 3 bedrooms New depth 0 in. 450+ g.p.d. If yes, give date - D. UFT STATION Date installed Size in gailons~ ~ Cycles tested Meets almm & circuit requlrementa? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WI=I I ONLOTTO: COMMUNITY WATER Septic tank/lift -tatlon on lot Abso~on field on lot Public ~ewer main On adjacent lots ------- Public sewer manhole/cleanout Holdlng tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO.- Building foundafion 5'+ Properly line 5% Water main 10'+ Water eendce line. 10'+ Wells on adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundafion 10'+ Surface water 100% Wells on adjacent lots 20o'+ Pmpertyilne 10'+ Wataree~celine 10'+ Curtalndmln NONE KNOWN F. COMMERT5 SYSTEM _.__.../ Absoq~fion field 5'+ Surface watar, lOO'+ Water main lO'+ Driveway, paddngfvehldestorage 10'+ G. ENGINEER'S CERTIFICATION ,~j~..~-./~ I ceJ~ ~het I have determined fhrough field In~N~:~ls mid review of Municipal records ~Jat #Je above qr~em~ are In conformance with MOA HAA guidelines In effect on this date. Englnee~e ~ Name JEFFREY A. GARNESS NAA Fee $ :~' Date of Payment Receipt Number ~/'~?' Waiver Fee $ Date of Payment Receipt Number GEl'Ii iFI()A i'E OF INSPEC-i ION l:Oi-i I'IEAL.'[Iq AUTi'IO~II i'Y APPNOVAL OF ONdalTE SEWER AND WATER FACILITY 264-4720 Application Date_ ~/%] _/..65 .................... GENERAL ~NF©NINA"~©Fa (a) Legal Description (include IoL block, subdivision, seciion, township, range) Location (address or alii'actions) (b) Applicant Namo ~.$?.S~l%J:.}k..~o~l-~i~,~d Telephone: Home (c) Applica::t is (check one); !_ending Institution E]; Owner/builder [3; Buyer (d) l.ending lnstF, ution _U.n:Lkod_ l:La~k_.~_Alaaka ..... lelephone Address 6~L5 ~ ~S h~_ee.t;.~ ta~l~aSD ALas_ka (e) ~,al E'Pate taompa;R/and Agent ViPgJ nj a Ko-1 ~1 eld, ReZ~,~ax Nea. li;y Address ~¢',~{1 o Ri~{'~?,,.._A-J_adks,___~Z .......... ~.~..~.~ Telephoned 9 h- :!:!2 ~0 (f) Mail ilia ', ',AA io the following address: Individ,'.~al t?'aF L] COnhmunlty ,,,or :.. If ~,( ~, n,uh:, w ..,, systcin, nil. l '-n, ,~ writiet~ col~fh ml tion from the Sklk} J)epaltinent ot Environmental {3ouserv'a~ion attesting to the legality and 4ta 4. SEWAGE DtSP©SAL Onsite E~ Public [i',} Community ti Holding Tank 11 Note: if community well system, must have written confirmation from the State Deparknent of Environmental Conservation attesting to the legality and sta~tus. 72-025 (11/84) Page 1 of 2 A:~ carfified by nly so~-d affixed hereto and as of the w~lidatio~] d~e ~;i~owi1 below, I ve[ify d~at -ny mvesti(~atJoi~ of this He~dth Authority Approw~i shows their tho on-site wa~ei supply ;. i~d/or wa~de,¢: tar d sposa syst } } is sale, functional and ~dequ{~te for the Immbgr et bedrooms and ~ype of structure Ii ,. K,dt(:)d lor,,In I fuithor verify th~z,t based on the infor~nabon obtained f:oirl the Municip~lity o~ Ancho:~ge files and fi-on'~ my investi9at~on ~snd inspection, the on-site wa~ter supply and/or wa~'~ewatet' disposal system is in conqpliatrlce wi(h ~11 Municipal and Sta~e codes, ordinances, and regulations in ~; .... on the date o~ this inspection. Apbroved for ' bedroorm; by D~te //_:%_.~ ......... ::: ........... AppFoved _ ;:?' ............ [;)iscfl3proved ~ ZL (::~nclidona~ Terms of Conditional Approval ................. : CAUT~©M °i-he Muncipalfty of Anchorage Department of I,taalth and Em/ironmental Protection (DHEP) issues Health A!:)prov~:fl cettffice, t{),'} based s~.4eIy t!porl the representations giveP, if] para9s~;ph 5 above by an independent professional en,c~ineer ~'egistered il-t tile State of Ah_~sl:a. The DH[iP cloes this as ~, courtesy to purchasers of homes and thai: [eF:ding institutions ii~ order ~o satisfy certain federal and st&~te reqLfirements. Employees of DHEP do not condu(;~ inspections or analyze data before a ce:[ific~tte is issued The Municip&qity et Anchora{~e is not responsible for errors or omissions in the professional e,'q,~iR~)eF's work. F)~C!e 2 of 2 Well Classification Well Log Present (Y/N) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: / / 7- /,/ ~!-¢ sC/ c/~-~ ~lf A, B, C, D.E.C. Approved (Y/N) /g" ~'e /~¢'/¢,- Date Completed Yield Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/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/Man hole Water Sample Collected by Water Sample Test Results Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date Comments SEPTIO~HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Size Air-tight Caps (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) ?~/'/~'/' Separation Distances from Septic/Holding Tank: To Water-Supply Well 2D¢/~' e , To Property Line //2 ~ To Water Main/Service Line /~ z- Course /~'~ No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped .-Sz ~-55 ; for Temporary Holding Tank Permit (Y/N) ,~'/ To Building Foundation To Disposal Field Z.-2 2¢ / To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /F'?~'~ 4;¢'/~/~,~8~ Date Installed ,} '~ ~ Width of Field ,~ c~ ,~ ~ ,~' ' Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ~0~'~ 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 Depth of Field Gravel Bed Thickness _ ~' / Standpipes Present (Y/N) . /J/ Date of Last Adequacy Test ~/'~ z-% , :)o / ';~-f~ , To Property Line To Existing or Abandoned System on ; On Adjoining Lots :::J~" t- To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons Dimensions Manhole/Access (Y/N) __ "Pump On" Level at ................... "Pump Off" Level at High Water Alarm Level at ...................... Vent (Y/N) Tested for Electrical Codes (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have cb;,ecked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed X~E*~/~--' Date _ ~/;:*'/q' ~-' Company /:7.. .-; MOA No. ~ Receipt No. ~ ~Y)7_.'I q,', Date of Payment ,,'., ~ Cv ) ........ Amount: $ Page 2 of 2 72-026 (I 1/84) ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA 99501 DATE: BILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 2~ To Whom it May Concern: According to records on file in this office the / i,/~:~ .~l. Water System is in compliance with the state Drinking Water Regulations Sincerely, Time Date Inspector Comments Time Date Inspector i, lermit No. Conditional Approval Sewer Installed Rating Septic Tank Size Holding Tank Size Well To Absorption Area Well Log Received Well to Tank Property Owner Mailing Address Buyer ..1 ~.:~ Address Lending Institution Address APPLICANT FILLS OUT LOWER HALF ONLY · ~ (2- , ( ~' (::~'~-'*-- '~ '~ ( ~ IPhone Realty Co. & Agent Address Legal Description Street Location Phone Phone Type~f Residence El' Single Family [] Multiple Family [] Other No. of Bedrooms Water Supply [~ Individual ATTACH WELL LOG. A well log is required for all wells drilled since June ~Community 1975. For wells drilled prior to that date, give well depth (attach log if [2 Public Utility available,) ~ Sewage Disposal .......................................................................... ~' Z~ '"-individual Year Individual Installed:__ "" ..... When Connected to Public Utility: ......