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HomeMy WebLinkAboutKIMBERLY MANOR BLK 1 LT 9•Cl Municipality of Anchorage Paee DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewaler Disposal Syslem and/or Well Inspection Report PermilNumber: 5~d(~)OI ~'-'~ PmDNumber: Ol~-0'7~- .,~e: ' / Waslewaler Syslem: O New ~ Upgrade LEGAL DESCRIPTION ~o,,.~,,,,~:~ ~o,~,. ~,. ,o,~,~,,, Lot: Block: Subdlv~ion: Oepll~ Io pipe bottom [rom 0r ' al grade: Gra~neath pipe WELL: U New ~ Upgrade Gravel widlh: ~ FI. IOislancebelweenlln;;:. Cl~sliio~tlo. (.HvaI..~.~.C): . Total Depth: Cased TO: Total abso~: Pipe material: ~rlge: . ¢ . Stalic Water Level: ~,~ ~Y~ ~' SEPARATION DISTANCES u Septic ~Hording U S.T.E.P. 10e' Material: %t2¢/ N.mber o, CompaHmenls: s.¢~¢;~ . ~: ] 100% ~ ~ LIFT STATION Remarks: [~z7,~¢ ~,¢F~c ~e~K p~¢4¢ BENCH MARK ' n, S & S ENGINEEEIN~ Inspections performed by: ~ie R!~e~, ~1..~. ws~ Dates:2nd. ~-1st ~ ~0oO~ ¢~~~.~.J ............ Deparlment of Heallh and Human Services approval t, ~,. Reviewed and approved by: ~~ ~ ~ Date'. 7-/~'¢ 0 ,,, 72-0t3 (Rev. 9/91) MOA 25 PERMIT NO SWO00127 PAGE 2 OF 3 DEPARTMENT OF HEALTH SERVICES ENVIRONMENTAL SERVICES DIVISION P.O, Box 196650 ©Anchorage, A~csko 99519-6650 © Telephone: 343 4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 9, BLOCK 1, KIMBERLY MANOR P.I.D. NO. 017 073 32 UPPER DeARMO OAD C03 c!C20 ~ ~,~,;,~,,,~..,~ .... ~ ~ ~ ROB~T C. COWAN ~ ~ ~ PERMIT NO. 8W000127 PAGE 3 OF 3 Municip. o,[i"c o¢/~[~hl~ 0~N DEPARTMENT OF HEA~,TH SERVICES ENVIRONMENTAL SERVICES DIVISION P,O, Box 196650 OAnchorage, Ataska 99519-6650 G Telephone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 9, BLOCK 1, KIMBERLY MANOR P.II). NO. 017--07.5--52 CO1 FINAL GRADE c,o, 2 (~¢) 91.5~ 97.9' C05 ALARM NEW 2000 GALLON HOLDING TANK ~-86.6' A B FCO 28.5' 24.0' CO1 70.0' 48.5' CO2 73.5' 56.0' CO.3 77.0' 62.0' MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: May 25, 2000 Expiration Date: May 25, 2001 Permit Number: SW000127 Legal Description: KIMBERLY MANOR BLK 1 LT 9 Design Engineer: 0003 S & S Engineering Owner Name: Oxy Relocation/Holly Briggs Owner Address: 5005 LBJ Freeway Dallas , TX 75244- Parcel ID: 017-073-32 Site Address: 007700 HILLSIDE WAY Lot Size: 34500 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: ~~'? ~/~ Date:;,~'' ~ ~-'- O ° Issued By: Date: ROBERT C. COWAN, P.E, SEWER&WATER INSPECTION WELL INSPECTION & FLOWTEST SOILTEST May 8, 2000 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519 REFERENCE: Lot 9, Block 1, Kimberly Manor S/D This letter is a request to issue a permit to upgrade the existing system with installation of a holding tank that will serve the three bedroom residence on the referenced property above. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. Attached is a site plan which depicts the locations of the existing septic tank and proposed holding tank, and test holes performed by Anchorage Water & Wastewater Consultants, Inc.v These soils tests show that the lot has no suitable areas for an on-site leachfield. & ~'~ ~'"~. If you require additional information, please contact us. Sincerely, Robed C. Cowan, P. E. RCC / jhm Enclosure 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 1" = 60' UPGRADE DESIGN SCALE ~ I ~ o ~oO~Zo ~ ?~ ~;o;;>..:1~ ........ xs~' lION 09:40 ,]~OK I~I{H£ P-,J~L £S1'~'1~ F~ NO. 9077823189 P. 06 Municipality of Anchorage. DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: C) '~('~/ J~ ¢¢ LO ('4' ~/ 0f'J C'O~'1/O'4~ ~' DATE PERFORM LEGAL DESCRIPTION:,~0T O) ~ £~ ! ~'lt'~/J~4'~¥/v~ t Township, Range; Section: SLOPE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O 13.0.11 · WAS GROUND WATER ~ ~ ENCOUNTERED? If YES, AT WHAT / I~ E Dale: Depth to Water Alter Monitoring? SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ TEST RUN SETWEEN COMMENTS B~ & S ENGINEER N6 .... ~_~CERTIFY 170~ Eagle River Loop Road No. ACCORDANCE ~J~,~~IPAL GUiDELiNES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) (minutes/inch) PERC HOLE DIAMETER __ FT AND FT THAT THIS TEST was PERFORMED IN ROBERT C. COWAN, P.E. SEWER &wNrER INSPECTtON ENGINEERING STUDIES AND REPORTS W~LL INSPECTION & FLOWTEST SOIL T£ST ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCE: Lot 9, Block 1, Kimberly Manor S/D May 8, 2000 GENERAL: 1. The scope of this project includes upgrading the existing system with the installation of a 2000 gallon holding tank to serve the three bedroom residence located on the referenced property. 2. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The contractor shall be responsible for obtaining any necessary underground utility locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. HOLDING TANK INSTALLATION: 1. A holding tank is to be constructed by a certified wastewater holding tank manufacturer. Construction shall include a 6" cleanout for pumping access, and water-tight manholes. 2. The holding tank shall be sufficiently bedded to prevent settling or shifting of the tank. 3. All standpipes on the holding tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Page 2 Lot 9, Block 1. Kimberly Manor S/D May 8, 2000 Holding tanks installed with less than 4 ft. of cover shall be insulated. The hold'mg tank shall be equipped with a high-water alarm which registers both visually and audibly inside the dwelling. The alarm shall be positioned to allow at least 150 gallons of storage per bedroom or a minimum of 300 gallons after the alarm has been activated. Final grading over the holding tank shall be such that a positive slope exists away from the holding tank. On areas of high ground water, sufficient weight shall be installed on the tank to prevent flotation. MINIMUM MATERIAL SPECIFICATIONS: 1. Any holding tank proposed for installation must be constructed by a Municipally approved holding tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F8 I0 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). 4. Tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). INSPECTIONS: Typically there will be a minimum of two (2) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: Page 3 Lot 9, May 8, Block 1, Kimberly Manor S/D 2000 The first inspection must be conducted after the tank has been set; lines, cleanouts, standpipes and insulation are in place; and prior to backfilling. 2. The final inspection is to occur upon final grading of the property. The inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractor's activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR / OWNER MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES Address TANK FIELD WELL LEGAL DESCRIPTION LOT LINE Township, Range, Section ' ~' / TANKS ' N Manufacturer Capacity in gallons Material No. of Compa~ments TYPE OF SYSTEM ~ TRENCH ~ BED ~ ' . DRAIN ~ OTHER Depth to p~pe bottom from To:al dept. from original grade °rigina' grade ~,~FT ~~~ FT Gravel depth be.eath pipe ~ :i'addedab°ve°riginalgr~ ~ FT O,~ F~ ~<~ Gravel width Total absorption area ~islance between lines instal[er Date installed WELLS X ~RIVATE ~ OTHER (Identilv) ~ Clarification (A,~.C) Total Depth Cased to I Date I~stalled; Installer REMARKS: ........ NGINEERI~G I ~ & s [ ......... cedily l~l this inspe~0n was ped0rmed according (o all [ ~~'~~ - ~ Ea le River ~ · Health Depadment Approval' l . _ ...... Da 72-013 (3/85) South l ork Construction P.O. Box 770567 · Eagle River, Alaska 99577 · 907-694-4551 MARCH 27, 1989 DUANE E. WERT INSPECTED THE ELECTRICAL WIRING AND TERMINATIONS OF THE ADD-ON LIFT STATIONS FOR THE UPGRADE OF THE SEPTIC SYSTEM ON LOT 9 BI3DCK 1 KIMBERLY ~iANOR ALL WIRING MEETS ELECTRICAL CODE. DUANE E. WERT STATE OF ALASKA ADMINISTRATIVE LICENSE ~D778658 CErtIFICATE OF FITN~SS ~88o4~5 !_ot, Lega 1: Subct :i. vi si:i. on: K I MBIERt_Y I"IANOFi I_o'L ',S~x::'l',. i on ~ .?,5 i_cit. Si;.:~ :34.800 (.sq. ft.. Hax Be~dr'c:,oms: 'T'l"iis F:'er'mi'L~ 3 Tot. al C::apac:i'Ly: 3 INSTAL. L. F:'EI::i'. A'I"I"ACI~!ED A~I:::'PNEIVEi:D I::'I.,..ANS,, l~4l::i"i',~;~ HA×IMLIH DEiF"IH i~ .... 2,' F'i~:~ ]: I?1"~ ]: N 1 () ' SEt:::'AI::;gYT' I EIN F:'FIOH Oi::i ]: G I ixlAI_ T'FilENCH. I::'F;X]V I DE ~DD I '1" I O1',1~.~,!... SCi I I_S I.,..OGS AS NECESSAI:'i'.Y. NC]T' ]: F:Y Df'IF'lB F:'N i i]R 'i'[] EACH :!: IgEiI:::'ECT :1: 011.I~:I,,,.IEC'I' l:;i :[ CAI,,,. F::'EI::iH I '1 I S RI:i%i!LJ I FilED l;::'[.ll::i '!.. i FT S:]A l i i]N., 'I"H 1S I::'IZIRM ]; T :[ S I '.SSLIIZD I::OFi'. THE EX I S'I" i: NG 3 BIE:DFi'.OEIH RES ! DIENCIE O!',lt_"i ANU IE X I:::' I RES tin I ;?.-:2; t ""'I3V. I CE;FiI'IFY 'THA'I: 1. I am familiar with t.h(.;~ r.e.'quir'exfm!r'rL,;;~i for orr,,.sit, e~ sewe~rs~ and v4e:.~].1~s asl sie~t, {ciP'Lh by t. he Hu. nicil:ialit, y of ¢~l'lc:hora(~i~ (Iff[IA) and ?.,, :1: will :i.n?rLall t,h(4~ siy~illt, i.:;,m in ac:c;cmciance~ wi'l:.h all and iiq cc>mp:l, ianc6? v~)i'i;.h 'Li"m:, ~Jc~;,~.~Ji"t c:r'it,~r'ia of t.l"li~; 3,, I w:i. tl aclhe~l"e~ t.o a;I.:t, MChq ar'id Stat.¢e o¢ A:!.asl<a i'.~qLiir'6xni.~?rYL!~ fl::/r' t. he .~i(.:2t. bac:l.:: c:!i~st, arl~:~.~ts f'r'.clm a!l"ly eiiJ,~t, irtg we].:l,~ wast. c~water' d:i.!~pcisal sy~t. em or'. public ~?v~EH"agfb? ~sysrt,.em or'i t. hi!F, oP any ad.jac:¢~nt, or I'l~aPl::ly lot.. a~].~i(:~ t. he (::apac:::i. ty of 'Lh~ 'l'..o'L,a]. ~y~rL~)m J.% :S l:lt?)cll"ocxn~[~; al"icl any e?r'ilar'gl.~ L,.~iPe an adclit, icinal Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: L.-<:~ ,i~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19, 20- ~/--I ~-d 1"'~ Township, Range, Section: ~-,~,~.~ ~.~_ SLOPE WAS GROUND WATER ENCOUNTERED? s IF YES, AT WHAT / ~) ~ DEPTH;) ! ~ p E Depth to Water Alter_ I Monitoring? \ c:::> Date: ~'~-~ SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE '~"~'~ (minutes/inch} PERC HOLE DIAMETER TEST RUN BETWEEN ~ FTAND ~ FT COMMENTS 72-008 (Rev. 4/85) February 16, 1989 ROBERT A. SHAFER CIVIL ENGINEER 694-2979 HEALTH AUTHORITY APPROVALS SEWER &WATER MAIN EXTENSIONS SEWER & WATER iNSPECTION ENGINEERING ~TUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANI~ ROAD DESIGN SOIL TEST p EflG~:~_ATiON '~ TEST MECHANICAL '. :',. INSPEC~ON8 .~ ON SITE · W,~TE WATER DISPOSAL SYSTEM DESIGN Ms. Nancy Bergh Pollock 2001 REALTY 1345 West 9th Avenue Anchorage, Alaska 99501 REFERENCE: Lot 9; Block I; Kimberly Manor Subdivision 7700 Upper DeA~moun Road, Anchorage, Alaska AHFC ~47871 D~r Nancy, At your request we have overseen the exploratory excavation of the septic system serving the referenced property. The excavation was performed by SOUTH FORK CONSTRUCTION. We observed a 1000 gallon steel septic tank buried approximately 5 feet to the top of the tank. The tank was in ~ood condition. The 4 inch PVC pipe exiting the septic tank had settled and separated from the tank. The 4 inch PVC pipe was followed for approximately 20 fe~t beyond the septic tank in search of a drainfield but none was found. We found no sewer rock, perforated pipe or other indications of an approvaSle drainfield. Therefore, prior to obtaining a Health Authority Approv~ (HAA) from the Municipality of Anchorage (MOA) la leaehfield needs to be installed to serve the r~idence located Ion the referenced property. Prior to/leaving the site a so~Is test was performed. Using this sow information we have obtained three bids (attaehedll fqr upgrading the ~epties~st~. you. have any questions or if we may be of further S~ruice, ~lease 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER. ALASKA 99577 BOX 1869. t!ITAR ~Rot,'T]B A ANCHOMGE. A.__LA. St[.~ 99502 ~-??14 SiX INCH WATER'W~LL DRILLtD' AND CASED OUT TO THE DEPTH OF ~I'T:: ~- DRILLED AT TH[ ~TE OF -: ~1~,00 PER FOOT. PROPERTY OWN~ ';::'~CATION. 0~: WELL S DRILLER~ ,.. .. - .... .WELL.,~Q} ........ -.-~-~ .... -~,. :~:=, ,:,.. e~¢~ . ....... · ~" '" ......' ' ' ":'~'~ "" ' ' ' COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. ~4,23.0. oo W~iTE CHECK' PAYABLE"TO':RAMPART'''[~RILLING:WORKS FOR THE SUM OF .'" THANK YOU VERY' MUCH. ' ~"":" ~ ' :;~' '-=~ ....... ' ' "' ' - BERNIE CLAUS OF RAMPA~ DRILLING WORK~ SERVICE CHARQEOF IVI% PER MONTH WILL S I::iF' ~::' L. [.( Ii~: i:::1NT I.... 0 C F:! Ti~ 13 L E)'..!iF:IL 'THIE l...c. 14L~ h E:, .I: HEN::E; :i: EII",I );'}; THFi' L..E;r.,!G"f'H ,::;[1'.,! F'E[ET', qF' TI'IL:i; 'I"!;:EH"H THE DEF'TH OF: I:::1 'T'I-~:E:NE:H OF:: F';[T :('.:~; THE D};:!:i;TFiI'4CE: .~:F(T.I[':;':}X.,~ THE '¢l:;;'f31JN[;:, FIN[) -FI..IIE E:CFf"Fi;::d"1 Ell::' TFIE [::,-.,L...,," t'.' ';1'.,I ,' :i;N F'EE'I"). T!...IEI:RE ~: :!:'; i'.4E~ :~!;E'T 1.4 :( DTH F:E B: 'T'!~:E:i'.,IC:HE:~:i. ..... ' .... f"~ [::,EF:'TH ;[:~-.:; THE H'rI'.,!:(I'qL.tH I:)EF:'TH qf:' qt:;;'Fl'v'E::J. FF'"Fb]E'E{N '1'HIE "' !"t"P:F:II J THEE ..:m: m, r ~. ................................ Rf',!I:::' 'i"FI!!E I~!:CITTEIh'I OJ:: "I"I"'IE F;;:':. Z .::l'v',':::tT r C! '-, ,' ]: N !:::'IJ:}LIET ::,. Z C:EF:T :!: [::'-r' 'FHFI'T' :I.: :[ F:!H FFti"I.'I:L]:t::IR HI:TH TH!i!i: Iq:E:IZ!t...I:[RI!i:HE~:N'T~:; F::E!F:: ON"~':~i;:/:'f'F~ :E;EI.,.IER:?i; F:OF:"FH E',"r' THE I',I!..JI'.,I:I:C:I:F'!::IL.:I:T"r' OF:' .'_:.::: :.r.I.,] Z L..L. ]: N'::~;TFtL. I... THE-': :~!;'-r":':i;TE:H Z N FICCOF';t[::'FiBIC:E !,.! :!: TH THE }!:: Z t...IN[.'.'Ei:;;'.'.F.:;'T'FIN[::' THI::t"f 'T'HIE Et[",!'"".:.;;):'F[{ ~'!;[ii:l.,i[):l:~: :i~!;"r':E;"f'.F}:I"! Pff:i'?' f~:E(~H.I:[Fi:E: E!:h,!L.F:ff;;:GE:i"tE:NT ]:F: 'THiE l:;:E:'.'_:i; :[ DEi",!E:E: ]: rE; I:;?.[~i:t'"IE~DEL.[ii:[':' TEl .'[ f',iE:[.IJ[::'E: HOI::~:E: 'f'HFIN :'!i: E:E[::'i:;~:OOI'"I~i~;. I:::iF'I::'L.'!,:CFII',FI" I'"tL.tNT[EFi: l,[..J' [. I::._': ..... I J I--IELL Flit-iD 01'-~--$ I TE PERMIT NO. < LOCRTION DEPRRTME~...~--~OF HERLTH FIND ENVIRAI'.,IrdEI'.t'f.~,~ PROTECTION, 825~ 'L' STREET, 8NCHORRGE., PK. 99501 ~ , LOT SIZE ~FOoLo SQLIRRE FEET TYPE OF SOIL RBSORBTION 5Y-c,t~EM IS: MR,~'~IMUI'I NUI'IBER OF BEDRO01"lS = ~.~ SOIL RRTING ('-'~Q FT/BR>= THE REQUIRED SIZE OF THE~ SOIL RBSORPTION SYSTEH IS: : [:"FF'TH= / / I ' El"4gTh= :73 i31~:R':,-'EL E-~EPTH THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENC:H OR 'DRR'rNFIEED. THE DEPTH OF R TRENCH: OR PIT I'-~ THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM: OF THE EXCRVRTIOr.,I (IN FEET). : THERE IS NO SET 1.4IDTH: FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH ElF GRR',,,'EL BETI4E~N THE OUTFRLL PIPE RND THE BOTTOM OF THE:EXCRVRTION (IN FEET). r REC-:LI I RE[:-, SEF'T I I_--. rTPI~"-JF~~. '---%' - I ZE: /OOC? I]¢iLLEir-4:5 PERMIT RPPLICRNT HRS THE i RESF'ONSIBILITY TO INFORM THIS DEPRRTMENT DUF.:ING THE INSTFILLRTION INSPECTIONS, OF RN'¢ WELLS FIDJFtC:EI'.,IT TO THIS PROPERTY, FIND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. ' EII~CKFILLINA OF IqN¥ SYSTEM WITHOUT FINIqL INSPECTION RND RPPR3VSL BY THIS DEPRRTMENT WILf BE SUBJECT T0 PROSECUTION.. MINIMUM DISTRNCE BETWEEN iCaO FEET FOR 150 TO 200 FEET FROM 8 PUBLIC WELL DEPENDING UF'ON THE TYF'E OF PUBLIC: klELb WELL LOGS FIRE REQUIRED RND MUST BE RETURNED TEl THE DEPRRTMENT WITHIN ~0 [:,RYS OF THE WELL COI'IPLETION. OTHER REQUIREMENTS MFIY RPF'LY. SPECIFICFtTIONS RND EENSTRLCTION [>IFIGRFIMS PRE FIVFIILRBLE TO INSURE PROPER INSTFILLRTION. F'ERf4 I T E×P I RES [:-,ECEr-IE:EF-: '~-'::1... 19 7'.- '_:-~- I CERTIFY THRT : · t: I RM FFIMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS FIND WELLS FIS SET FORTH BY THE MUNICIPRLITY OF FINCHORRGE. 2: I WILL INSTRLL THE SYSTEM IN RCCORDFINCE WITH THE CODES; 5<: I UNDERSTFtND THRT THE ON-SITE SEWER SYSTEM MR"r' REQUIRE ENLRRGEMENT IF THE '¢_R. 2 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 r PHONE EW D UPGRADE MAILING ADDRESS gy • t f g O LEGAL DESCRIPTION e, rg '1 LOCATION NO. OF BEDROOMS DISTANCE TO: Well '0- 1 f Absorption area Dwelling r' 1 PERMIT NO. " az Manufactur Material No. of compartments Cnw Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth o DISTANCE TO: Well Dwelling PERMIT NO. 2 Manufacturer Material Liquid capacity in gallons G1 _j 3: LU DISTANCE TO: Well f Foundation Nearest lot line PERMIT NO. —2 _j tL 5 No. of lines Length of each line , Total length of line Trench width p Distance between I" 1= = x t T f 5 inches Top of the to finish Material beneath the cc grade r 7 Total effective absorption area A Length Width Depth PERMIT NO. ut H wLu� Type of crib Crib diameter Crib depth Total effective absorption area Cn DISTANCE TO: Well Building foundation Nearest lot line a Class Depth Driller Distance to lot line PERMIT NO. a DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING 0 INSTALLER eu REMARKS t t 1 iia lff w �t AFPROV � DATE LEGAL 1 72 i3 iRev: 178) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99502 276-222~ SOILS LOG -- PERCOLATION TEST SOILS LOG [] PERCO L'ATION TEST ASI No. 01279 PERFORMED FOR: D.M. & G. Construction, Inc. (contractor) Hunter Henderson/.ownpr) ' DATE PERFORMED: 4/5/79 LEGAL DESCRIPTION: 1 2 3- 5 6 -._.7 8 9 10 11 12 13- 14- 15 16- 17 18 19 Lot 9, Block 1, Kimberlv Manor Subdivision Organic Silt, Dark Brown GraVelly Silt .w/Tr. Sand Lt. Brown, Si. Moist Ocn, Cobble Sand w/some silt. (SP)' Silty Sand (SM) w/Tr. Gravel Ocn. Cobble T.D, Dry, Lt. Brown SLOPE (ML) I WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SITE PLAN , Gross Net Depth to Net Reading Date Time Time Water Drop ]1.: 25 4/5/79 0 0" 11: 35 4/5/79 10 11:45 4/5/79 20 2" 11:55 . 4/5/79 30 2%" 12:05 4/5/79 40 3" 12:15 4/5/79 50 3~" 12:25 4/5/79 60 3 5/8" 20 PERCOLATION RATE h! TEST RUN BETINEEN COMMENTS NO frost or ground water observed.- ~'~J~lr_~.~.~--.,,.~e,.¢,~~-11 ', from · sand pocket. Parcel I:D. Municipality of Anchorage Oepartmont of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 RD. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION HAA# H 4 ©ooo ~'c~ Expiration Date: Completelegaldescription 1,o~- q, Rlnr-k t, Location (site address or directions) 7700 Upper Dearmoun Current Property owner(s) Scott Sindelar Dayphone972-404-''3949 Mailing address 5005 LBJ Freeway, Dallas, TX 75244-6119 ATTn: Holly Lending agency Mailing address Day phone Real Estate Agent Day phone Mailing Address ---~/~. ~/ Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] [] Individual Holding Tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) 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 title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. 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 are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72 025 (Rev 01,001' 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 based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. S & S ENGINEERING 17034 Eagle River Loop Road No, 204 Name of Firm Eagle River, Alaska 99577 Phone ~o 5~ ~ - ~.-~ -7 c/ Address Engineer's Printed Name Robert C, Cowan Date ?/' .... .,~,. / t~,. j.~ ;... ~ :.:....:~ ~: ~.~' ~ bedrooms, with the following stipulations. DHHS SIGNATURE Approved for ,~ bedrooms. Disapproved. Conditional approval for Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: /0- J~ - O0 Original Certificate Date: Reissue Date: 75 025 ~Rev 01 001' Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L' Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 wwvv. ci.anchorage.ak.us (907) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /CT c~ ~L--~c~c I A. WELL DATA Well type ~'/~ ,,vPr~'~. If A, B, or C provide PWSID # Date completed~ / ~ J~7"/ Sanitary seal Total depth ~'~' ~ ft Cased to 3- 3. I ft FROM WELL LOG Date of test ~ / 1 ~/7 ~] Static water level /:~/ ft Well production / 'O. g.p.m WATER SAMPLE RESULTS: Coliform. o colonies/100 mi Nitrate ). Date of sample: 7/I,~/~o Collected by: SEPTIC~TAN K DATA Tank Type/Material Date.installed ~o/~-~./; O. Tank size ~- ~ o o gal Clear~outs ¥'~J Foundation cleanout Date of pumping Parcel I.D.: Well Log "/& 3 Wires properly protected ¥~-~ Casing height (above ground) /~, in. AT INSPECTION '"'~ /1'~ /o o I~2 ft g.p.m __ mg/I Other bacteria o colonies/100 mi S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Number of Compartments High water alarm Depression over tank Pumper ABSORPTION FIELD DATA Date installed _ Soil rating (g.p.d./ft2 or ft2/bdrm) ~ Length ft Width ft Grav~p~pe __ _ff _ . Total depth _ _ .ft Effective absorption area/ft~ Monitoring tube Depression over field.__ Date of adequacy test __~ (Pass/Fail) _ __ For __ __ bedrooms Fluid depth in abs~ before test __ _ in Water added __ gal. New depth__ Elapsedy__ mi,n, F~I~!.~ d~epth_ in Absorption rate >= __ Any regiment (past 12 mo.) (Y/N & type) If yes, give date in. __ g.p.d. 72-026 (Rev. 01/00)* D. LIFT STATION Date installed . Size in gallons ~ "Pump on" level at ~n High water alarm level at in Datum ~ Cycles tested Meets alarm & circuit requirements_ SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot /v /.~ On adjacent lots Absorption field on lot ¢///~ On adjacent lots ¢'00 '¢' Ioo -t Public sewer main .~ /,4 Public sewer manhole/cleanout Sewer/septic service line ;~ 5'/4 Holding tank 7 0 SEPARATION DISTANCES FROM SEPTIC-~'~OL-E~G TAN~ ON LOT TO: Building foundation z¢ 6 Property line ,-¢ Water main '~/4. Water service line Drainage ,~/~, Wells on a. cl:ja'0'ent lots Ab,.serClo n field Surface water / co -~. SEPARATION DISTANCE FRO~PTION FIELD ON LOTTO: Property line ~ Building foundation__ _ __ Water main Wa~ Surface water Driveway, parking/vehicle storage Cffrtain drain Wells on adjacent lots F. COMMENTS G ENGINEER'S CERTIFICATION I certify that , have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. i,; ~ .... "' ¢ ,.. Engineer's Printed Name ~OB~,4 )-- C. ~o ,.,¢,,¢~ HAA Fee $ Date of Payment Receipt Number 3 oo, 3/q /o,~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 01/00)' Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 vc~vw, ci.anchorage.ak, us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 017-073-32 1. GENERAL INFORMATION Complete legal description ExPiration Date: LOT 9~ BLOCK 1 KIMBERLY MANOR Location (site address or directions) 7700 UPPER DEARMOUN ROAD Ms. Theresa Sindelar Day phone 345-5203 7700 Upper DeArmoun Road. Anch. AK 99516 Day phone Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing Address U.S. Inspect Day phone (800) 872-3660 extension 431 Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked ~p by: NUMBER OF BEDROOMS: 3 3, TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] [] Individual Holding tank [] [] Community On-site [] [] Public Sewer [] The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Certificates of Health Authority Approval (HAA) 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 title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS aiso issues HAAs upon request to home owners 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 ihan 30 days old Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 5. 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 based on procedures outlined in the Health Authority Approval Guidelines for 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 site water supply and/or wastewater disposal system is in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone En,q. Svc. Address P.O. Box 102954, Anch, AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. DHHS SIGNATURE Y Approved for 3 Disapproved. Conditional approval for Phone 272-8218 Date 2~22~2000 bedrooms. ~ . . ~ bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisor,./ Well Flow Advisory Expiration Date: X Maintenance Agreements Supplemental Engineer's Repod Other v Original Certificate Date: ~ - / '~--¢ 0 Reissue Date: Municipality of Anchorage Department of Health and Human Service AR 09 ,000 Division of Environmental Services On-Site Services Section 825 "L" Street Room 502¢,ur~e~c~i P.O. Box 196650 Anchorage, AK 99519-6650 www.oi.anchorage.ak.us (9~07) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST LOT 9, BLOCK 1 KIMBERLY MANOR Legal Description: A. WELL DATA Well type PRIVATE Date completed 6/18/1979 Total depth 221 ft Date of test Static water level UNKNOWN Well production UNKNOWN WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi Date of sample: 212112000 B. SEPTIC/HOLDING TANK DATA Parcel I.D.: 017-073-32 If A, B, or C provide PWSID # __ Well Log Y Sanitary seal K Wires properly protected Cased to 221 ft Casing height (above ground) 16 in. FROM WELL LOG AT INSPECTION 61191t 979 2/19~2000 ft 132 ff g.p.m 4.0+ g.p,m Nitrate 1.5 mg/I Collected by: S.R.PANNONE Other bacteria 0 colonies/lO0 mi Tank Type/Material STEEL Date installed 8/28/1979 Tank size 1000 gal Number of Compartments 2 Cleanouts Y Foundation cleanout Y Depression over tank N High water alarm .N/A Date of pumping 2/23/2000 Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA Date installed 3120/1989 Soil rating (g.p.d/ft2 or~.244¢~ System type BED Length 53 ff Width 30 ft Gravel below pipe 0.5 ft Total depth 3 ff Effective absorption area .1590 ft2 Monitoring tube Y Depression over field N Date of adequacy test 2/19/2000 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test _4 in Water added457 gal. New depth6 in. Elapsed Time: 1440 min Final fluid depth _4 in Absorption rate >= 457 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) UNKNOWN NONE INDICATED If yes, give date (Rev. 11/99) D. LIFT STATION Date installed 3/20/1989 Size in gallons 500 "Pump on" level at ~',¢ in"Pump off" level at /-'~--~. in Datum ~ ['"~'FI'-0~ ~'~'c~A4C Cycles tested 10 E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septictank/lift station on lot 120 Absorption field on lot 130+ Public sewer main N/A Sewer/septic service line 90' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access YE~ High water alarm level at '~/~'- in Meets alarm & circuit requirements? Y Building foundation 39 Water main 100 Drainage 100+ On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout N/A Holding tank 100+ Property line 10+ Water service line 100 Wells on adjacent lots 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 50 Surface water 100+ Wells on adjacent lots 100+ Absorption field 10+ Surface water 100+ Property line 10 Water Service line 85+ Curtain drain 100+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Steven R, Pannone, P.E. Date 2-25-00 Water main 100+ . Driveway, parking/vehicle storage 85 HAA Fee $ Date of Payment Receipt Number (Rev. 11/99) Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 9, Block 1, Kimberly Manor Location(address ordirections) 7700 Upper Dearmoun (b) Property owner A.H.F.C. ~47871 Telephone: (home) Mailing Address 520 E. 34th Ave., Anchorage, Alaska (c) Lending Institution Telephone Business Mailing Address (d) Real Estate Company and Agent Address 1345 West 9thr Telephone 276-2001 2001 Realty/ Nancy Berqh-Pollock Su. 201, Anchoraqe, Alaska 99501 (e) Mail the HAA to the following address: (or check herP~:~, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle River Loop Road No, 204 Eagle River, Alaska ~2~577 2. TYPE OF RESIDENCE Single-Family [] Number of-bedrooms 3 3. WATER SUPPLY Individual Well ~ 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 I~ 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 I of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION . As certified by my seal affixed Iieretoand as of thevaJidationdateshown below, Iverifythat my investigation of th is 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 Telephone _~'c~2/__./~ ~¢.¢,7~;~ S & S E,~!GI.NEEP-!HG 17034 Eagle River Loop Road No. 204 Address ~_~,~ o;.,~., ^1..~.~ oo~ Date ~/Z~/~ 6. DHHS APPROVAL Approved for ~' bedrooms by Approved ~,~ Disapproved Terms of Conditional Approval Conditional The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph S 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 inordertosatisfycertain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. TheMunicipalityofAnchorageisnot responsible for errors or omissions in the professional engineer's work. 72-025 (Rev 7/88) Back Page 2 of 2 ~ MUNICIPALITY OF ANCHORAGE (MOA) '--LICY ~,~'~[~TC~,~AG~ Health Authority Approval (HAA) MUN[Ow --~IvIsiON CHECKLIST - FEBRUARY 1984 · . 343-4744 ~,~R 2 8 19 9 Legal Description: ~--~c~'~ WELLOAT2, ECEIVED Well Classification ~ r-~ ¢-.-.-.~ \ J \ Well Log Present ~}~/N) ___/%f__ Date ~Completed Total Depth ~¢-t I Cased to ¢-~--~ D~pth of Grouting ----" Static Water Level V¢~¢-'"' Pump Set At Casing Height Above Ground \'2~ Electrical Wiring in Conduit (~N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Fiel_~n Lot To NeareSt PUblic Sewer Line If A, B, C, D.E.C. Approved (Y/N) -./,~ Yield ~"-', '¢¢'~f"'1 -'Jr- To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments Sanitary Seal on Casing ~)N) Depression Ardund Wellhead ; On Adjoining Lots ~-'% ~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole SEPTIC/HOLDING TANK D,A~/~. ~ -~ '~"~ Datelnstalled '~'~1 ~S~'/O~ }~.~>c> No. of Compartments Standpipes ~2i~N) "~ ^b-tight Caps~N) Depression over Tank (Y/~j) ~ Pumping/Maintenance Contact on File (Y/NXI} . Holding Tank High-Water Alarm (Y/N) I' '"(' Foundation Cleanout Date Last pumped / /'~ ; for ~ Temporary Holding Tank Permit SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line To Building Foundation To Disposal Field To Stream, Pond, Lake or Major Drainage Course Comments .~ ~q3~t~- ~"~. \~. 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~-~ ~ ~ Width of Field '¥ ~ Square Feet of Absortion Area Depression over Field (Y~I;) Results of Last Adequacy Test Type of System Design Length of Field ~--z~ Depth of Field ~ Grave[ Bed Thickness o¢,~" \ ~-~ c,"P' Statndpipes Present ~N) ~-J Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: I To Water-Supply Well To Building Foundation L.¢ ~ Lot ~ ~ To Water Main/Service Line ! ~ ~4- To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) Comments D. LIFT STATION Date installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for I'~ MOA Electrical Codes(.(CT/N) Meets Comments Dimensions '¢¢¢¢d", L~(~, ,¢~yl\oII E:::~)~, Manhole/Access (4~7N) "Pump Off" Level at Vent (~/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 inspection. Signed Company Date MOA No. S & $ 17034 Eagle River Loop Road No. 204 Eagle R~ve.¢, Ail~sb:a ~.~5~"~ Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 APPLI( "NT FILLS ouT UPPER HA~, 'ONLY Prol~erty~ Owner 7'/~ ~ ,/~/i/~7 .~ /~/~.. f ...~) ~ ~?~ ~/~ ~ ~ Phone Buyer Address Zip Code Lending Institution Phone Address Zip Code ~ Phone Type of Resi~nce ~ Single Family ~ Multiple Family No. of Bedrooms ~ Other Water~ IndividualSUpPiY ~3~{ ~OQ ~ AWACH WELL LOG. A w~l log is required for all wells drilled since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal ~ Individua~ Year Individual Installed: ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Insp~tor Insp~r Fie~a Note~ ~NIO¢A~IW OF ANCHO~E t~ ~ ~ I ~ DE~. OF HEALTH ~ ENVIrONMeNTAL PROTECTION ~AR ~ ~ ~g83 RECEIVED ( ~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) GONDITIONAL APPROVAL* Soils Rating Date ~wer Installed Well To Absorption Area /~ Well Log R~ceived ~ ~ Well to Tank ~ ~ Septio T~k Size 72-023 (3182) ~ DATE RECEIVED " ' INSPECTION APPOINTMENTS ~)ME TIME TIME DATE DATE INSPECTOR INSPECTOR INSPECTOR DEPT. OF 1!7:ALTH & MUNICIPALITY OF ANCHORAGERoTECTioNENVIRONMENTALp F'~:OTECTION  DEPARTMENT OF HEALTH & ENVIRONMENTAL 825 L Street - Anchorage, Alaska 99501 FEB 5 1980 ENVIRONMENTAL SANITATION DIVISION Te,epho.e R E C E l V D REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten {10) days for processing. ~. PBOPE.TY MAILING ADDRESS PROPERTY RESIDENT (If different from above) :2. BUYER PHONE ~ MAILING ADDRESS 3, LENDING INSTITUTION I PHONE I MAILING ADDRESS '4, REALTOR/AGENT / PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION 6. 'r~'Pg OF RESIDENCE [~ SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One [] Four [] Two [] Five ~ Three [] Six [] Other 7. WATER SUPPLY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8.SEWAGE DISPOSAL SYSTEM y INDIVIDUAL/ON-SITE*' [] PU,L,C UT, L,~Y YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) 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 [~] PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: /~¢~-~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line ] Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS ~ APPROVED FOR ~ BEDROOMS ~ CO~DITIO~Ak AP~BOVAk {letter must a~co~pan~ certificate) ~'~ DISAPPROVED DATE ~ 72-010 (Rev. 6/79)