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Home My WebLink AboutMCMAHON BLK 1 LT 20i~ 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 I I OPGRADE LEGAL DES~IPTION LOCATIO/N t NO, OF BEDROOMS DISTAN;E TO: ~ ~Z ~ Manufacturer Liq. ca~aci~.y i~gallons Inside length Width Liquid depth /~;~ IF HOMEMADE: O ~ Well Dwelling PERMIT NO. DISTANCE TO: O z ~ Manufacturer Material Liquid capacity in gallons ~ Well Foundatio~ Nearest~3 _~'~, No. of lines/ Length 3e~ line Total leng ~f~nes Trencij~h inches Distance be~l~S;ion ~ Top of tile to finish grail, Materia, b~neath tile Length ~dth Depth . ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE ~ATER~ALS ~ . ,.~ REMARKS 72-013 (Rev, 3/78) BOX ~9, ~?AR ]~OU?E A ANCHOI/AGE~ ALA$KA 9950~ SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF DRILLED AT THE RATE OF $2O. OO PER FOOT. Property owNer /7~. //lcJ~ B~L~Jg 345-3142 245 LOCATION OF WELL SITE DrILLEr WELL LOG: 0 ..... 18' 18 .... 45~ San. d~ q,,m~eZ. IOy/o 116--172' S,CL~ co~ g~n~t. 40% oLo~ ~r~. 172--226' l~e~ ~ ur2~. 30,% 226--141~ $.LL~ we_~ q.4xz~ed... 20% c2w. q.. Sonze~ um,.Le'a p~ocb, w.2.~n, aL 141 .f_4. " 0 Co,~,~ o~ ~,~U_~9: ~4900.0 f~o Ch.o~o~ ~.o~z Ued~L SeaL. COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYable TO RAMPART DRILLING WORKS FOr THe SUM OF $4900.00 THANK YOU VERY MUCH. DATE. BERNIE CLAUS OF RAMPART DRILLING WORKS SERVICE CHARGEOF I~% PER MONTH WILL BE ASSESSED OPA UEACC UNT$. RPPL I CFtNT BEETER CONST. LOCRTION LESLIE & MCMRHON LEGRL L20 Bi HCMRHON T'T'PE OF' SOIL RBSORPTION S'¢STEM f'IRXIHUM NUHBER OF BE[.',ROOMS = 4 DE~'RF.'.TMENT ¢"~' HEFILTH FINE:, E[.,I',,~! RONMENTRL "-~.:OTECT 825 '3_ STREET, RNCH~RRGE., FIK. SRR ~546E 2:5000 SI';~URRE FEEl' LOT SIZE I'=;: TRENCFI SO I L F.'.RT I NG ( 'E C-., FT,,"BR .'., = o~- _ _ . '-]' "-T'''''~ I S THE REC]LIIRE[:, SIZE OF THE SOIL RB'-]¢~RF'TION =T=..=.,. : THE LENGTH DIMENSION IS THE LENGTH -'.':IN FEET) OF THE TRENCH OR DRRINF!EL[:'.' THE [:,EPTH OF R TRENCH OR PIT IS THE DISTRNCE E,'E'¥NEEN ]"HE SURFRCE OF THE GROUN[:' RND THE BOTTOM OF THE EXCRVRTION (IN FEET). '=" FOR TRENCHES. THERE IS NO _,ET WI[:,TH THE GRRVEL DEPTH IS; TFIE MINIMUM [EF]H OF GRRVEL BETNEEN THE OUTFRLL PIPE RN[:, ']'HE BOTTOM OF THE E,'-'..*,CR',/RTION (IN FEET). F:E,g."LI ][ F:EL], "~,EF"T I C: T ~-'~ [-,~ ~-'-':] ~; ][ ZE= :-t-2~-5~;'~ aZ~F~b.L_ Ca~..,~'~-~ PERMIT RPPLICFtNT HRS THE RESPON$IBILI'F'T' TO INFORM THIS DEPFiRTMENT DURING ']"HE INSTRLLRTION INSPECTIONS OF RN"r' WELLS R[:,JRCENT TO THIS PROPERT~r' FIND THE NUMBER OF RESIDENCES THRT THE NELL HILL SERVE. BRCKFILLING OF RN'¢ S~'STEM NITHOUT FINRL INSPECTION RN[:' RPPROVRL B'¢ THIS DEPRRTMENT NILL BE SUBJEC'f' TO PROSECUTION. MINIMUM DISTRNCE 8ETNEEN R NELL RND RN'¢ ON-SITE SE['.IRGE DISPOSRL S~'STEf"I IS ±OE"~ FEET FOR R PRI',/RTE NELL OR 250 ".FO 200 FEET FROM R PUBLIC NELL DEPENDING LIF'ON ]"HE TYPE OF FUELI-. NELL IS '":'~' FEET MINIMUM DISTRNCE FROM R F'RI",,'RTE P.IELL TO R PRIVRTE SEWER [_INE ..... TO R RrMM NIT'¢ .=,EIDER L. INE IS ':"~ FEET. .... [,]ELL LOGS RRE F. tEC!LIIF.:EB, RND MUL:;T BE RETURNED TO THE [:,EF'RRTMENT NITHIN Z.:R IF THE NELL F:rMPLETION. OTHER REL.]UIF. tEMENTS f'lR~r' FtPPL'¢. =,FECIFICN. TIUN~., RND COM':;TR_CTIf]N [.IHG~.HM=, FIRE R',,,'RILRBLE TO INSLIRE PROPER INSTFILLRTION. F'E]F:f'I :E 'T EXF" ?[ F:E25 [:,EC:E[r. IE:EF..: _~..-: :.t.. I CERTIF'¢ THRT :1.: IRM FRf'IIL. IRF'. P. IITH THE RE'.,)UIREMENTS FOR I]N-SITE SENERS FIN[:, NELLS RS :BET FCRTH B'¢ THE MI..INIL. IFh_IT'r OF RNCHORRGE. ;.::: I WILL INSTRLL THE S~'STEM IN RCCORDRNCE NITN ]"HE CODES. :,T=,,r=~ MR'~' RE6~LIIRE ENLFIRGEMENT IF THE 2:: I LINDERSTFtN[:, THRT THE ON-SITE SEWER ,-,,,-T .... . RESI[:,ENCE IS REMODELE[:' TO INCLU[:'E flURE THRN 4 BEDROOMS. RF'PL ICRNT E:EETER L. UNz, T. ..... -,7 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-550, Anchorage, Alaska 99502 276-222f SOILS LOG -- PERCOLATION TEST -~-~:~ 10, 11 12 13- 14- 15- 16 17, 18- 19- 20- DATE PERFORMED:__ ~. /SOILS LOG PERCOLATION TEST : SLOPE SITE PLAN Garth O. Talbot 'No. 4069- E COMMENTS 72-008 (7/76} WAS GROUND WATER, ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN (minutes/inch) FT AND -- FT 1977 976677 Deants Saathoff 7002 Cuttysark Anchorage, A~a~ka 99502 Permit Ex~)irat~on Dear Mr. Saathoff~ A permit issued by this department for well and/or on-site sewer installation on Lot 20 Block 1 Mc ~honsSubdivision has expired sinc~ the issue date exceeds one (1) year. In the event you still plan to ~nstal_ the we1! and/or on- site ~wer system~ a new permit is required. The original soil test may be- used to obtain a current permit. If the well ims been drtlled~ a well log should be sent to this department to document the installation date. If you have any questions regard~qg the above matter, please do not hesitate to contact this office immediately at 264-~ 4720. ~i~cerely~ Les N. B~chhotz~ R.So Sani~a~ian ~ c N .t"l [)F;~i Di:;?.FI i r..l'- ] I=l ~. THE E;L.IF;:F:'I:::!C:E~ C~F:' THE E:E'T'I,Jiiii:E~N Tl"lJlii; [)i. HI'T'~::'J:::II....L.. J=' ]: GREATER ANCIIORAGE AREA Department of Environlnenta] Quality 3330 "C" Street Anchorage, Alaska 99503 SOILS I,OG -- PEROI,ATION TEST Legal Description: ~._ ~ This form reports: Soils log Date Performed.._T~.~' / 2~' .7 ~} Percolation test Depth Feet 1 - 2- 3- 4- 5- 6- 7- 8- 9- I0 - ll - 12 - 13 - 14 - Was ground water encountered? If yes, at wltat depth? .............. Reading Date Gross Time Net Time Depth to Water Net Drop ~ercolation rate m~nute. · Proposed installation: Seepage Pit Depth of Inlet ................ · Dept'h 't~'-~-~--~:Fpit or trench COMMENTS: August 3~ 1977 ~76580 Den~s Saathoff 7002 Cutt~aakk ~nchorage, Alaska 99502 subject: Permit Expiration Dear Mr. Saathoff: A per~%it issued by this depart~ent for well and/or on-site sewer installation on Lot 20 Block 1 Mc Mahon Subdivision has expired stncethe issue date axeeeds one (1) year° In the ~vent you still plan to Lnstall the %qei1 and/or on- site sower system, a new permit is required. The original soil test My be used to obtain a current permit. If the well has been drilled, a well log should be sent to this department to document ~%e installation date. If you have any questions regarding the above matter~ please do not hesitate to contact this office i~mediately at 279- 2511, extension 224 or 225. Sincerely, LeS N. Buchholz, R.~o Sanitarian i::l F'i:::' L i[ i~i: I::t ~',~ ' ~' ii::'~:~:i ,'t' J i~ ~q '.:~;FtR T PIEIF' F~_ ..... F:iT'i""'N LE::E;L]:['~ :~;T ,..." i"IE:h'tF~HON F~',,,'E H :[ N ;1: hlLih'i I)]: :STRNE:E E',ETNEEN FI HEL. L ::i. EiP. i F'F:%'I" ~::'t;;;t~;: R F'R);',,,'FI"FE HELl... OE~ 21~:.1l~;t F'EET F:'O~'. F~F'LIE:L];E~HE;L.L.. ¢:::~i::: 'i"I.-iE !.,.iEL. L COHF'L. ET :[ ON. ~ ~ ,/ ..... :SF'EE: :i: F' ): (:::FIT Z I:::l[.,i$~; I~h,lE:, CEIN%TF~:LtE:T i ..,:::~',: I ~ F ~ THR'I" :J.: :( i:::ihl F:'F:II"I Z L. :l: i::t¢~: [,.I :[ TH 'FIE F .I~.H i:::E~F~:"FH E:'.r' 'f'HE HIJN]C:[F'RL q"'¢ OF RNCH'" .... :;~:: :~: ~.,~:~..~.. ~'.~:~:'?~':,u.. '~-~-~: ~¢~:'~-~:~','~ z~.~d::,:::,::,~:~::,r*~.~,::~:: ~..~:[~'~.~ "r,~ ,::,::,::,~:~:. H 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 20; Block I; Mc Mahon Subdivision; Location (site address or directions) 4001 Property owner Mailing address Lending agency Mailing address Paul & Carolee Rusanowski Day phone 4001 Mc Mahon Av~.~ Anchorage, Ak. 99516 248-0597 Day phone Agent Fr¢.nk Address 2600 ~¢mdm~ -q.~. Anohn~ag~.; Ak 99503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well XX Community well NOTE: Dayphor~e. 257-0145 Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: XX Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1191) Front MOA #21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that 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 Address 17034 Ea.~le River L~op i~oad No. 204 Engineer's signature Phone Date DHHS SIGNATURE ' Approved for Z~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: .~c5 H/-,3 c-~Vl/'C~d Date (~/?/c~ / 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 order to 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~O25 (Rev. 1/91) Back MOA~Y21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~/_0"/-',2.O; _,~Joc../~'. 3 i~,.~,~o,d .=%,~Parcel I.D. A, WELL DATA Well type ~-~u~~ If A, B, or C, attach ADEC letter. Log present (Y/N) /-i ~ ~ Total depth ~- ~ ~ / Sanitary seal (Y/N) L1 Date completed Cased to ~- ~ ~ Casing height FROM WELL LOG Date of test Static water level '-' Well flow Pump level Absorption field on lot SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /oo Public sewer main Public sewer service line Wires properly protected (Y/N) g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: ~, Date of sample: ~ -- !/-/ -~ I Collected by: Other bacteria ~: c ~'~ B. SEPTIC/HOLDING TANK DATA Date installed Z -2 ?- ~ ~ Tank size I ,~ ~0 ?~/ Compartments Cleanouts (Y/N) ~ Foundation cleanout (Y/N) [,~ Depression (Y/N) . High wate,-~larm (Y/N) /~/l/~ Alarm tested (Y/N) .... -fit Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot { ~ 0 / On adjacent lots To propertyline 2..0 ' Absorption field ~:) ~ Water main/service line Surface water/drainage 72q)~6 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump~' level at ;'egelsW;~ rAal la~o~ rli;~i lo o d es (y/N)~ SEPARATION DISTANCE FROM LIFT STATION~: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed Length ~ ! _Width Total absorption area Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Depression over field (Y/N) Results (pass/fail) r/')~ '-'-'-'-'-'-'-'-'~,¢b Peroxide treatment (past 12 months) (Y/N) Surface water Soil rating ~ ~ ~/~:~! ,~ System type Gravel thickness In Total depth /_ O Cleanouts present (Y/N) Date of adequacy test ~ - / ~-- ~' / for d bedrooms /~/~ If yes, give date /~/~r SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots ! CO/¢' Propertyline 2. Z. ,~' t To existing or abandoned system on lot Cutbank /0/~, Water main/service line Driveway, parking/vehicle storage area Well on lot / /~ O To building foundation On adjacent lots ~ ¢9 '~ Surface water / t30 '~' Curtain drain __/kJ/~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of thls"ifiSpection. Signature [~ & 5 .......... ~ ......... Engineer's Nam~gle River, Alaska Date -¢/~ ~ ~' ( HAA Fee $ / 0 0, f/jO Date of Payment ~ /'"~'._L~/¢~' / Receipt Number .~,,.~ F'/ (7/0 (~/~--7~') Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 Client Sample ID:L20 E1 MCI~AHON S/D PWSID :UA Collected }4AY 14 91 ~ 14:20 h~s. Received [&~Y 15 91 @ 14:45 h~s. P~eserved with :AS REQUIRED ANALYSIS REPORT BY SAWLE for MORKorderU 34257 Date Repo~t Printed: I~Y 17 9i fi 16:17 Client Name :S & S ENGINEERING Client Acct :SNSENGP BPO $ PO ~ NONE RECEIVED Req ~ Ordered By :R. SHAEER Analysis Completed :}dAY 17 91 Send Reports to: Laboratory Supervisor :STEPHEN C. EDE / lis & S ENGINEERING Released By :~~/~ 2) Chemlab Re£ ~: 912023 Lab Smpl ID: 5 Matrix: WATER Allowable Parameter Tested Result Units Method Limits NITRATE-N 4.3 mE/1 EPa 353,2 10 Sample ROUTINE SA}dPLE COLLECTED BY: R.D.J. Remarks: i Tests Pe~£ermed See Special Instructions Above UA=Unavailable ND= None Detected ** See Sample Remarks.Above NA= Not Analyzed LT=Less Than, GT-Greater Than MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date August 15, 1986 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 20, Block 1, HcHahon Subdivision~ Sec. Location (address or directions) Applicant Name Paul Rusanowski Telephone: Home 3b,5-2539 Business 276-/4~02 Applicant Address b,00! HcHahon Avenue, Anchorage~ Alaska Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain); (b) (c) (d) Lending Institution /~/~ Address Telephone (e) Real Estate Company and Agent Address N/A Telephone (f) Mailthe HAAtothefollowingaddress: Tryck~ Nyman & Hayes 91! West 8th Avenue Anchorage, Alaska TYPE OF RESIDENCE Single-Family [] Multi-Family [] Number of Bedrooms Four Other WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) E~IGINEERING FIRM PROVIDtI~ INSPECTIONS, TESTS, FILE SEARCH, Dh, A AND INFORMATION 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 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 Tryck, Nyman & Hayes Telephone (907) 279-0543 Address 91] West 8th Avenue, Anchorage, Alaska Date August 15, 1986 Approved for .~¢~¢~' bedrooms by Date ApProved ~ Disapproved Gonditioh-al~ Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The 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 DHEP 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. Page 2 of 2 72-025 (11/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: LO[ ZU, B]ock~ ] HcHahon Subdivision Well Classification Well Log Present (Y/N) Total Depth 295 ~ Static Water Level Casing Height Above Ground 20" Electrical Wiring in Conduit (Y/N) Yes Separation Distances from Well: To Septic/Holding Tank on Lot 160 ~+ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line 300 '+ Cleanout/Manhole ~00 ~ + Single Fami Iy IfA, B, C, D.E.C. Approved (Y/N) N/A Yes Date Completed Feb. 28, ]981 Yield 4.8+ gaI./min. Cased to 245 ~ Depth of Grouting unknown 165' Pump Set At 241 ' Sanitary Seal on Casing (Y/N) Yes Depression Around Wellhead (Y/N) No ; On Adjoining Lots ]75'+ (lot 19) 160'+ ; On Adjoining Lots 17~;'+ (lot lg) To Nearest Public Sewer To Nearest Sewer Service Line on Lot N/A Water Sample Collected by Tryck, Nyman & Hayes ; Date 8/12/86 Water Sample Test Results Sat i sfactory Comments All lots in.immediate area served by on-site water and sanitary sewer.systems. B. SEPTIC/HOLDING TANK DATA Date Installed 2/27/81 Size ] ,250 qal, No. of Compartments Two (2) Standpipes (Y/N) Yes Air-tight Caps (Y/N) Yes Foundation Cleanout (Y/N) Yes Depression over Tank (Y/N) No Date Last Pumped 5/25/86 Pumping/Maintenance Contract on File (Y/N) No ; for N/A Holding Tank High-Water Alarm (Y/N) N/A Temporary Holding Tank Permit (Y/N) . N/A Separation Distances from Septic/Holding Tank: To Water-Supply Well ] 60 ' To Propedy Line 20 ' To Water Main/Service Line 3001+ Course 300 '+ To Building Foundation To Disposal Field 21' 38' 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 85 Type of System Design Date Installed Feb. 27, 1981 Length of Field 3 ] ~ Width of Field 36" Depth of Field LI8'~ 372 S,F, (calculatGer~eI Bed Thickness 72" Square Feet of Absorption Area 340 S,F, (record) Standpipes Present (Y/N) Depression over Field (Y/N) No Date of Last Adequacy Test Results of Last Adequacy Test Adequate Separation Distance from Absorption Field: To Water-Supply Well 160 ~ To Building Foundation 22,9 ~ Lot To Abandoned System To Water Main/Service Line 300~+ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Lot 20 is corner lot, Lot Leach Field Yes 8/12/86 To Property Line 20'+ To Existing or Abandoned System on ; On Adjoining Lots 100'+ (lot 19) To Cutbank (if present) N/A 300'+ 40'+ 19 is contiguous lot south of property. D. LIFT STATION Date Installed N/A Size in Gallons N/A "Pump On" Level at N/A High Water Alarm Level at N/A Tested for N/A Electrical Codes (Y/N) N/A Comments N/A Dimensions Manhole/Access (Y/N) N/A "Pump Off" Level at N/A Vent (Y/N) N/A Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitt/~e.~room Re.st HAA Request ** I certify that I.~e c/h~/C<ed, v~ri~/e~conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed _/~//~~ -.~.~ 7~ Date . , - 5~. · . ....... ~.. Am~-nt.e $65 00 72-026 {11/84) ~ D A'I"~ RECEIVED INSPECTION APPOINTMENTS 0 MUNICIPALITY OF ANCHORAGE ~~) DEPARTMENT OF HEALTH & ENVIRONMENTAL PROT~ALi~ OF ANCHORAGE 825 L Street - Anchorage, Alaska 99501 DEPT. OF HEALTH & ENVIRONMENTAL PROTEC ~ION E~Vl ROBBE~TAL SA~ITATIO~ DlVlSlO~ , Telephone 264-4720 Ir.~AY ? ~981 ~ DIRECTIONS: Complete all parts ca page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing, 1. PROPERTY OWNER PHONE MAILING ADDRESS-- ~ ~ W PROPERTY RESIDENT (If different from above) PHONE PHONE MAILING ADDRESS */O ~ '~tt F--' ~''~ PHONE MAILING ADDRESS 4. REALTOR/AGENT I PHONE I MAILING ADDRESS · STREET LOCATION 6. TYPE OF RESIDENCE / NUMBER OF~BEDRO~MS [] One ~ Four SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six [] Other 7. WATER SUPPLY ~ INDIVIDUAL~ [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON,SITE** [] PUBLIC UTI LITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVI DUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBL,C UT, L,TY Connection Verified INSTALLER Size:_ ~%~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAl_ ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank rea Line Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS ~APPROVED FOR ~ BEDROOMS ~ CO~DITIO~Ak A~OVAk {letter must accompan~ certificate) ~ DISAP~BOV~D DATE BY 72-010 (Rev. 6/79)