HomeMy WebLinkAboutLITTLE BEAR BLK 1 LT 9
PERMIT NO.
RF F L I ~.FINT
LOCAT I ON
LEGAL
DEPARTMENT ' HEFILTH AND EN'v'IF,'ENMENTf:It_ 'E:OIE...FION
25'±E~ E. TUDOR F:[:,.., FtblCHORRGE;
ED F-'. Z NI",IER.
BABY BEAR PLFICE
L9 E:t LITTLE BEAR S.."D
WELL. z, LE -~ CT
8~±0 - '- -"
LOT
:5: ,:1-,4 -4 fl_ 7."; :!.
:L:M.'.:Tf~ S(;:!UF-IRE FEET
MINIMUM DISTANCE BETWEEN R WELL AN[.'.', ANY ON-SITE SEWAGE DISF'OSAL. S'¢S"FEM IS;
tOE~ FEET FOR A PRIVATE WELL OR 2E~E~ FEET FOR A PUBLIC WELL
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITNII",I L:':¢.'".~ [:'R'T':5
OF 'THE WELL. COMPLETION.
SPECIFICATIONS RND CONSTRUCTION DIFIGRAMS ARE A',/AILRBLE TO INSURE PROPER
INSTALLATION.
I CERTIFY THAT
1: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-'.:.;ITE SEWERS AND WELLS RS E;E:T
FORTH B'? THE MUNICIPALITY OF ~NCHOR~GE.
2: I WILL INSTBLL THE S~'~TEM IN ACCORDANCE WITH THE CODES.
RPPLZCRNT ED R ZNNER
0 0 0 0 0 0 0 0 0 0 0
!.
Z
Parcel I.D. #
1.
014-061-26 ~
GENERAL INFORMATION
Complete legal description
MUNICIPALITY OF ANCHORAGE
. DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box lg6650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
' HAA#'
r, ot 9~ BlOck 1, 'nittle Bear S/D
Location (.s!te address or directions) 6641 ]~3y Bear Drive
Property owner sherrie Bancroft Day phone
..Mailing address. 6641 Baby Bear Drive, .~a~chorage, AK 9950?
561-7511
Lending agency
Mailing address
ConsUmer Mortgage/Bryan~~ ~artin . Day phone
500 E. Tudor, Suite 101, Anchorage, AK 99503
770-7845
Agent
Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 '~
3. TYPE OF WATER SUPPLY:
Individual well
4,
Community well
Public water
NOTE:
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
. .. Individualon-site
. :' Holdtngtank
~_ ~ Community on-site
' xxx
' PUblic sewer '
NOTE`.
If'Community well system, provide written confirmation from State ADEC attest-
If'community wastewater system, ProWde written confirmation from State ADEC
attesting to the legality and status'of s~/stem. -'
72*025 (Rev. l/gt) Front MOA I21
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 s~,stem 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
Engineer's signature
S & $ ENGINEERING
170~o, ~aOl~ River Loop Road No.
Eagle River, Alaska 9957,7
Phone
Date.
DHHS SIGNATURE
~/~ Approved for
Disapproved,
Conditional approval for
bedrooms.
rjp ~ ROBERT C. COWAN: / ~ ~
bedrooms, with the following stiPulations:
Additional Comments
By:
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 omlssi0ns in the professionai engineer's work.
72-025 (Re~'. 1/91) Back MOA f~21
APR Ob
Municipality of Anchorage '
DEPARTMENT OF HEALTH & HUMAN SERVICES ~ur~,, ~ ~ ^~I~)
Environmental Services Division ~Ny~o~
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
LegalDescription:L.o-F- c~ ~.~: / £~7~,~ /~/ZX//C ~'/'-~ ParcelI.D.: 0~-O~ /-~
A. WELL DATA
Well
type
Log present ~.~N) ~/~- J; Date completed
Total depth ~' ~' Cased to H ~' ~
Sanitary seal (..~N) ¥'~ ~¢
If A, B, or C, attach ADEC letter. ADEC water system number
Casing height (above ground)
Wires properly protected (~/N)
FROM WELL LOG AT INSPECTION
g.p.m.
Date of test
Static water level
Well production
g.p.m.
WATER SAMPLE RESULTS:
Coliform O
Date Of sample: 3 / J ~//~]
a. SEPTIC/HOLDING TANK DATA
Nitrate co- 5~ Other bacteria o
Collected by:
S & S ENGINEERING
17034 Eag',~ E~ve~ Loop Roa~l NO. 20,{
Eagle River, Alaska 99577
Date installed
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Length Width
Effective absorption area
Date of adequacy test
Tank size Number of Compartments ~'r~C]~e~a~outs (Y/N)__
Depression (Y/N) High..w~er alarm (Y/N)
Pumper ~
Soil rating (g/~./ff2 or ft~/bdrm)
~Gravel thickness below pipe
/~Monitoring Tube present (Y/N).__
Results (Pass/Fail)
System type
Total depth
Depression over field (Y/N) __
For
Fluid depth in__eld before test
(in.);
Fluid depth//' (ins) Minutes later:
bedrooms
Peroxj ed~treatment (past 12 months) (Y/N)
Immediately after gal. water added (in.):
Absorption rate = .g.p.d.
If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) "Pumjp~~
High water alarm level ~a~;*~~--j *Datum
CycJ.es~t~r~'~~'
E. SEPARATION DISTANCES
F.
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot /v /R
Absorption field on lot I'¢ //9-
On adjacent lots
On adjacent lots
· '7.¢ ~' Public sewer manhole/cleanout
D- .~- -/~ Lift station
Public sewer main
Sewer/septic service line
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation Property line -- ~.~_~
Water main/service line .Surface water/drainage _.~- Wells on adjacent lots __
DISTANCE FROM A~OT TO:
SEPARATION
Property line ,...--"Building foundation __ Water main/service line
~'~ rea
Surface water ~ Driveway, parking/vehicle storage a
C~ain Wells on adjacent lots
ENGINEER'S CERTIFICATION _,~.~.~%,~ ~,~
I certif that I have determined thru field inspections and review of Municipal reco~t~(;fbe'abe~ ~s are
. Y ..... ~,'~ .,,' .... .~_ ~
/n conformance w/th MO~ H~ ou~del/n~ /n effect on th~s date ~ ~ / ~ '.. ~-~ ~
Engineer's Name l~0¢5¢~~ ~-o~,_,¢¢~ ~ Ros~tb. cow~r~:
Date _ · ~, ~;...,, · ~... ¢~
. '~.-¢,,, . ,,,.
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
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 9; Block 1; Little Bear Subdivision
Location (site address or directions) ~6,~3 RRby Rc, R¥', Anchorage, Alaska
Property owner Janet Jones Day phone 349-6641
Mailing address 6641 Baby Bear, Anchorage, Alaska
Lending agency Day phone
Mailing address
Agent Beth Simpson/SIMPSON COMPANY, REALTORS Day phone 345-1020
Address Huffman Place, Suite 203, 12350 Industry Way, Anchorage, Alaska
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
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.
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.
99515
72-025 (Rev. 1/91) Front MOA#21
'~JO~ S,J@@U!bUe IBUO!SSgJoJd 9LI~ u] SUO!SS!LUO JO SJOJJ~) JOJ elq!suodseJ
~ou s! ebeJoqouv ~o ~!led!ojun~ aqJ. 'penss! s! e]eo!j!~J@9 8 @Jojeq B~,ep ezAiBue Jo suojlo@dsu! ~onpuoo
~ou op SHHQ ~o seeAoldLu~] 's~ueLueJ!nb@J m,e~s pu~ 18J@pe~ u!e~J@~/gs!~es o~ JepJo u! suo!~n~Rsu] bu!pu@l J!@ql pub
setuoq ~o sJas~qoJnd o~/,saU noo e se s!q~ seop SHHC] eq.l. '~selV jo e~e~,S eql u! peJels!BeJ Jeeu!bue i~uo!ss@joJd
~uepu@depu! ue Aq e^oqe g qdeJBeJed u! u@^!D suoj~B~uesBJd@J eq~ uodn Aluo p@seq ~a)~o!J!~J@O le^oJddv
A~poq~nv q~leeH senss! ($HHQ) seoFue$ ueuunH pue q~leaH ~o ~UeLUuedeQ eBeJoqouv ~o A~!led!o!unl~
sjuewwoo leUO!l!ppv
:suop, elndp, s I~U!MOIIOj eqj ql!M 'suuooJpeq
Joj le^oJdde leUO!~!puoc)
euoqd
'SLUOOJpeq ~'
'peAoJddes!C]
Joj p@^oJdd¥ /~
;~I=IrlJ.YN~DI$ SHHa
eJnjeuS!s s,Jeeu!Bu=l
sseJppv
LUll4 Jo eUJeN
'uop, oedsu! s!ql jo m, ep eq), uo ~,oejje u! suo!~elnl~eJ pue 'seoueu!pJo
'sepoo m,m,9 pue led!o!unlAI lie q~!M eOUe!ldLUOO u! s! LUre, SAS lesodslp Je~eMejSeM ~o/pue Alddns
~m, eM el!s-uo eq~ 'uop, oedsu! pue uoReD!~seAu! ALU ~uoJj pue seliJ eDeJoqouv jo A~!led!o!unl/N eq~
LUOJJ peu!m, qo UO!jeLUJOJU! eq~ uo peseq ~,eq),/~J!JeA Jeq~nj I 'u!eJeq peleo!pu! eJ n~,onJ~s jo ed,~ pue
SLUOOCpeq JO JeqLunu eq), ~oj m, enbepe pue leUO!jounj 'ejes s! uJm, SAS lesods!p JeleMejSeM Jo/pue
Alddns Je~,eM e),!s-uo eqj ~,eql SMOqS uo!lea!ldde leAOJdd¥ ,9, poq~,n¥ q~,leeH s!ql bo uoReSp, seAu!
Auu ~,eq~, Ajpe^ I 'MOleq UMOqS m, ep uo!lep!leA eq~ jo se pub ojeJeq pex!JJe leas Auu ~q peij!laeo sV
bF~NIgN::I ),8 NOIJ. O~dSNI .dO J.N~IlN~]J.YJ.S
'9
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Descr pt on: ~ ?, ~'/// ~/77'/_~ -~¢~¢fL '~ Parcel I.D.
A. WELL DATA
Well type
Log present~l)
Total depth
Sanitary seal (Y/N)
Date of test
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed /- ~z- ~- 5;z Driller
Cased to ~S / Casing height
Wires properly Protected ~N)
FROM WELL LOG AT INSPECTION
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot okJ/~- ;On adjacent lots ¢-"//~./
Absorption field on lot ~/~ ; On adjacent lots /v~,,,~"
Public sewer main /00 ~ Public sewer manhole/cleanout /~f--) ~
(~r_.~' ~ro F,O Ob Petroleum tank ~d0roG_
Sewer service line ~ ~+ ~JO~r~
WATER SAMPLE RESULTS:
Coliform ~ Nitrate (/~¢ ~'-~ ~¢-/~ Other bacteria
Date of sample: ] ~- ~-~ Collected by: _~ ~r:-~'
High water alarm,(Y/N) ~ ~
Date Of pumping: .~' ~ Pumper
SEPARATI ON DIsTANcE~G TAN K~
Well(s: on I°t' ~ i! Foundation -"-----.
~rr On adjacent lots
~ line Absorption field Water main/service line
Surface water/drainage
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
led Manufacturer
Size in gallons~'"'~ Manho~
'
Vent (Y/N) ~-~- "Pump off" level at
High water alarm level Cycles tested
Meets MOA electr~
SEPAR~TANCE FROM LIFT STATION TO:
Wel~J.-ed lot ______ On adjacent lots __ Surface water '-----.._
D. ABSORPTION FIELD DATA~cJ~J/~ ~ ~)/'~ ~)t2~(~lC~ ,_.~d.,/d~'-fl,~
Soil rating System type
Length ~ Width Gravel thickness T~r-..
Total absorption area '"""%._ Cleanouts present
~;~it~siO;siV~,; eld (Y/N) ~ Date o~ e~quacy t~st
Peroxii:~realm::t (past 12 months)(Y/N)'~~'~~/~' ~ '---- '~.-'~ "~ If yes, giveZ bedrooms
On adjacent IoJ¢ Cutbank__ Water main/service line ~'-~_
! u~ Driveway, parking/vehicle storage area
,,.~u rtain d rain
E. ENGINEER'S CERTIFICATION (
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect of this inspe tion.
Signature
Engineer's Name
Date
S & S ENGINEERING
17034 Eagle River Loop Road
Eagle Riveh Alaska 99577
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Location (address or directions)
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Telephone: (home)
(b) Property owner ~. I'"/ /'=
Mailing Address ¢(~
(c) Lending Institution
Telephone
Business 5-3 ~ - / ~- Z 2
Mailing Address
(d)
Real Estate Company and Agent
Address ..~ ~--.~ O '~" ~'7
Telephone ~-~ ~: - / ~ ~ ~
(e)
Mail the HAA to the following address: (or check here r~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family r~ Number of bedrooms
3. WATER SUPPLY
Individual Weld [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
A. WELL DATA
Well Classification
Well Log Present (Y/N) ~"
Total Depth ~'~' Cased to __
Static Water Level ( 'E. 5' *
Casing Height Above Ground ~ ~"
Electrical Wiring in Conduit (Y/N) Y' :~
SEPARATION DISTANCES FROM WELL:
E~N MUNICIPALITY OF ANCHORAGE (MOA)
LI~Y OF/~l~..t~.orily Approval (HAA)
TAt. S~RVJ~L~I~L.~i-. FEBRUARY 1984
RECEIVED
DateCompleted I /
343-4744
Legal Description:
Depth of Grouting N,~.
Pump Set At ~/~'
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
If A, B, C, D.E.C. Approved (Y/N)
Yield ~ ,=,n~,
To Septic/Holding Tank on Lot N,/I.. ( ?~6/;c $~,~,-~; On Adjoining Lots H,/~.
To Nearest Edge of Absorption Field on Lot f/,~. ; On Adjoining Lots
To Nearest Public Sewer Line I'~ ~ To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments D~ ~(
No. of Compartments
Air-tight Caps (Y/N)
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N).
B. SEPTIC/HOLDING TANK DATA
Date Installed Size
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments ~/~r¢
To Building Foundation
To Disposal Field
72-026 (Rev. 7/88) Front Page I of 2
C. ABSORPTION FIELD DATA h/,,4.
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~,~-, J:::, ¢¢~ c~n~ .~c ¢r~,~ /-~
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
D. LIFT STATION /~,A.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed
Company
Date
MOA No.
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
~ ~' ~*' .... ' · ~.¢~ =ngneersSeal
Waiver Fee: $
Date of Payment
Page 2 of 2
MUNICIPALITY OF A/gCHOP~AGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRC~qMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPRCi~AL CERTIFICATE
1. General Info~-mation
Appi
ication Date
Legal t~scril~tion (include lot, block, subdivision, z~.~tion, tu;~nsh'ip, range)
(a)
Location (add~'ess or directions)
(b) Applicants Nam~ ~, ~ { l>,g,,~?¢/ /'~ .~ ,~.~,,,,,.,/ Telephone
Applicants Ad.ess ~ ~ ~ ~ g~____
(c) Applicant is (check o~) ~nding Institution ~; (~er~uil~r ~
Buyer~ ; Other ~ (e~lain); __~/~__,
(d) ~nding Institution ~, ~ ~~~ TelqphoneJ2
(e) ~al Estate 'Co. & Agent ~ C.~ ~ ~, ~ ~ ~3.~ ~C/~
Telephone ~ >~ -~.~_~
2. ~ of _~esidence
Single-Family
Nun~zer of ~edrooms
Ymlt i-Family ~
S
Other (describe)
3. r~ te_____r.. Supp!y.
Individual ~bll ~ Community ~ Public ~I
Note: If community %911 system, must have written co-nf.~mation from the State
Depa~tn~nt of ~nvironmental Conservation attesting to the legality and status.
Is the w~ll adequate for the number of kedroo,~ specified in this HAA (Y/N)
4. Sewage DisDosal
Onsite ~ Public ~ Ccmalunity ~ Holding Tank ~-~
Is the wastewate~ dispcsal system adequate fc~ the numter of bedrooms (Y/N)
[Page 1 of 2]
OHEP Approval
Approved for
Appr °~'~d ~
Engineerinq Firm Providing. I__nspectiens, Tests, Data and Information
I certify that I hav~ checked, verified, cr conforr~d to all MOA HAA Q~id~lir~s
effect on the date of this inspection°
. ~"- ~'
~% ~%' JqO. 2225-5
(~'¥:~% ~UNE 25, 1971
DisaD~o~d ~ Conditional ~
Terms of Conditional Approval
line Municipality of Anchorage Department of F~alth and Enviror,~rental Protection
not guarantee the continued satisfactory performance of the water supply and/c~ t~
wastewater dispDsal system. This approval indicates that, as of the validation
sho~n abcve~ b3.~d on hl~ data and information furnished by an engineer registere~
the State of Alaska, the water supply a~d wastewater disposal system is safe and
tional for the rmmfoer of bedrooms and type of structuz, e indicated.
( DHEP SEAL)
7. Mail the HAA to the following address:
KB2/d5/s
[Page 2 of 2]
ae
Well Classification
Well Log P/resent (Y/N)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Total Depth ~ ~ Cased to
Static Water Level ~5 ~ '
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation DistanCes f~om Well:
To Septic/Holding Tank on Lot..:_d~-
To Nearest Edge of Absorption Field on Lo~.~
MUNICIPALITY OF ANO4OP~GE
DEPT. OF HEALTH &
ENVIRONMENTAL PRoTeCTIOn4
If A, B, o~ C, D.E.C. Approved(Y/N)
Date Completed I/7/ 77 Yield
?
Depth of Grouting. ~
Sanitary Seal on Casing (Y/N) %/
Depression A~ound Wellhead (Y/N) ~
; On Adjoining Lots,~.
-~ ; On AdjoiningLots.~-~
Pump Set .At
~, ~.2-- / ~2% ~) TO Nearest Public Sewer
To Nearest Public Sewer Line~ . -, .
Cleancu~/Manh~le ~(~ To Nearest Sewer Service Line on Lot
Water Sample Collected By ~,~ ; Date
Water Sample Test Pesults ~'D .~~
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Air-tight Caps (Y/N)
Date Last Pumped
No. of Cc~oatrt~ents
Foundation Cleanout (Y/N)
Pumping/Maintenance Contract on File (Y/N) ; for
Holding Tank High-WaterAla~m (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances f~om Septic/}{olding Tank:
To Water-SupplyWell
To P~operty Line
To Water Main/Service Line
Course
To Building Foundation
To Disposal Field
To Steeam, Pond, ..Lake, c~ Major D~ainage
Cou,'~nts
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
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes P~esent (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To P~operty Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank(if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking A~ea, or Vehicle Storage ~ea
· CoL~0~ nts
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Ala~,mLevel at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
~ets MOA
Comments
** Check Permitted Bedroom Rating Agains~ HAA Request
I certify that I have checked, verified, o~ conformed to all MOA HAA C~ideli~s in effect
on the date of this inspection.
KB1/d5/s
[Page 2 of 2]
~--~ MUNICIPALITY OF ANCHORAGF~'~,
~F' FtEAL'I'It AND ENVIRONMENTAl_ PROTEC'TION
- Q ~-
825.. ~ S~ree~, ~chorage, Alaska ~9~0]_
/ 279-2511, ex~. 224, 225 :
Time 1:30 p.m. 2nd inspection: Time
Date 3-22-77 Tuesday
Date
Inspector Dixson InspecEor
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES'
1. Lending Institution Request: Alaska National Bank of North
Mailing Address: Pouch 7-010 Calais'II Phone: 277-5511
2. Property Owner:
Mailing Address;
Donald Dahl
Phone: 344-5720
Star Route A Box 79
Lot 9 Block 1 Little Bear Subdivision
3. Legal Description:
Permit %76310
4. Single Family Residence: (x~
Multiple Family Residence: ( )
Number of Bedrooms:
Number of Bedrooms:
e
Well Data: Type In__d~vidual _~Depth 88 Well. Log Filed
Construction ~~~'--~//Bacterial Analysis=
Sewage Disposal System: On-site system [ ) Public Utilihy
Permit ~ Installed Installer
Septic Tank Size
Manufacturer
Absorption Area
Soils Rate
Material
Distances: Well to Septic Tank
to Sewer Lines Nearest Lot Line
Absorpumon Area to Nearest Lot Line
to z~sorption Area
Page Two . ' ~. .. ~
:.. - ~ ' ~,Depar~ment of~ Hea-lth and~Envir'onmental Protection
. Request f~r: Approval of Individual Sewer and Water Facilities
Legal Description: Lot 9 Block 1 Little Bear SubdiVision
Comment s:
Approved: ~~-~
Disapproved:
Letter Attached: ( )
Date:
Deparhment Worksheet:
MUNICIPALITY OF ANCHORAGE MUNICIPALITY Ol: ANCHORAGF
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTS' 0~: ~', ','~ 2510 East Tudor Road, Anchorage, Alaska 99504 276.2[~b~i, iRONMENTAi'
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: CMRO VA FHA_
RECEIVED
CONV
2. Property Owner:
Mailing Address:
3. Name of Buyer:
Mailing Address:
Tlnn~ld ~b} dba Dah} Construction
box 79 ~tar ~oute A Day Phone: ~44-5720
Day Phone:
4. Name of Lending Institution: A!?_ske_ .~.a~!ona! ~ank of ','he North
Mailing Address: C21aais ~ld II 3301 C Streep~on~.~uch 7-010
5. N'ame of Realtor or Agent: Esther Bumgardner w/ 'l'otem Realty
Mailing Address: 724 E. 15th Ave. Phone: Wk. 272-0571
6. Legal Description: Z~ ~' ~/~ / ~" ~ ~ ~ ~.
Location: B~y ~r ~mivm ruff l',~ka Of.i~ l~ft at. ~:. Aath than
277-55I~
~ome344-I933
l~¢f.n nff E.68th.
Type of Facility to be Inspected:
No. Bdrms. 3
Water Supply
Type of Supply: Public Utility
If Individual, number of dwellings presently served
If Individual, depth of well _,L~I~!
rlndividual
/
Sewage Disposal System
Type of System: Public Utility
If ndividual, date of installation ~/~
Individual (on-site)
72-003(3/76)