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HomeMy WebLinkAboutHIDEAWAY HILLS BLK 2 LT 2  MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING [)IV)SION 825 L Street- Anchorage, Alasl<a 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WEI.L INSPECTION REPORT NAME IP~SN~ ~L~ ~ NEW MAILING ADDRESS LEGAL DESCriPTION Nd. OF BEDROOMS ~ ~ DISTANCE TO;___I~O~L ~ ~ Manufacturer Mater~ No. of compartments Liq. capac~ in gallons Inside length Width Liquid depth ~ IF HOMEMADE: I  Well Dwelling PERMIT NO. DISTANCE TO: ~ E ~ Manufacturer --'Material Liquid capacity in gallons ~ W~I] F~unda ........ PERMIT NO. DISTANCE TO: FO ~ ~m~ ~ ~ lines~ Length~f each line ~ ~o, of Total lenqth~f li~es Trench width Distance between lines ~ ~ Top of tile to finish grade Material beneath tile Total effectiv~bsorption area Length Width Depth PERMIT NO, ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well BuildiRg foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance tO lot line PERMIT NO. ~ DISTANCE TO: Buildin9 foundation Sewer Pine Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING REMARKS V , A - ~r,,%.. JUNE 25. 1971 ~'~ ~2.. .'~N~ ~ ....... F~F'PL I C:FtN-I" I..J3CFIT I O1",1 !...EGFIL. T"r'F'IE ElF' '.'.50 ]: L FIEE~;CIRF:'T I Ed'.,I S'¢S'TEH ! S: 'I"REt",ICH MFI::.::IMLIH NUMBER OF:' E:E[:,ROOH::2; = 5 '.:.:;CILL r~::FITING (;.:.;C-.! FT,.."BR)= ;.]::7'5 THE REQUIRED E..;I;:.ZE: OF: THE SOIl... RBSORF"T'ION :'.C,'¢STEM IS: 'T'HE LEI'.,IG]"H DIP'IENS]:O?',! IS THE LENGTH ,.';IN FEET) ElF THE TREI'.,ICH OR [:,RRII",IF'IEL[:,. THE [:,E::F'TH OF t:1 TRI.~:I'.,ICH EIR PIT I~:; TF.I[< [)I~]Tt::II',ICE E',E:.]"P.IEEN THE !51jRF'FICrF.: Cfi: THE GROUND I:II'.,tD ]"HE E~OTTOM (:iF' THE EXCFI',,"FfTION ,:: IN F'EE:T). THEF.:E IS I'.,10 SE]" 14IDTH F()R TREI'.,ICHE'}~;. 'T'HE GF.'.FI',,,'EL [:,EF'TH IS ]'HE MINIMIJH DEF'TH OF GI.;..'FI',,,'EL. E',ET!4EEN THE OIJTFFILL F'IF'E FIN[:, THE BOTTOM ()F ]"HE EY, C:FI',,,'FITION ,::IN FEET). F:'E R H I T F:IF'F'L I C RN T HRS T HE RE S P O N S I B I L I T'T' T O I I",IFI.]F.:H TF'I I S DE F:'R R T HE I",t'T [:-"UR I I",!G 'I"H E t t',ISTRLLFIT I ON ]: N'..E:F'EE:T I CIi"4~ L]F RN"¢ .[,.IE:LLS FI[:'JFICENT TO TH I ~ F'RFIPEF;'.T"r' FII",ID THE I",IUME:ER OF RE';::SIDEI',ICES THRT THE I.'.tELI.... P.IILL SER',,,'E. BRCKF I L..L. I t"4G OF FIi",I"~" S'¢STEM l,-! I TH(JUT F I IqRL I NSPEE:T I O1',t FIN[:' FIPPRO',/FII... B'¢ TH I S DEF'FIRTf'tEI'-4T 14 t L.L [.:.]E SIJEh:rEc T TO F'RCi:E;E:CUT I (3t'.,I. H I i'.,t I MIJM [:, I STFiI'.,ICE E:IE]"FIEEN FI ~4E[..L FIND RI",I"? ON-S I ]'E SEI.,.IFIGE f.':, I SI:::'i]~SFIL. S'¢STEM I ."E; J..E'~I.;} FEET FOR FI F'RI',,,'R]"E NELL OR :1..5~2~ TO 2E~E~ FEE]" FROM R PIJBI...IC NELL [:,EPEI',IDING UF'ON THE 'T"¢F'E OF F'UE:LIC NELL. MINIHUM DISTFII'.,ICE FROH R PRIVF!TE HELL TO FI PRI',,,'FITE SENEI~: LINE IS 25 FEET FIN[:, TO FI E:OHHLtt',tIT'.r' SENER LINE ]:S 7'5 F'EE'F. OTHER I;;:E6!L.I I REMENTS MFI'¢ FIF'PL"r'. '.'SF'EC I F' I CFIT IONS FIN[:' COi",t':];TF.:LICT 101'4 [:' I I::IGRFII'"I:'5 RRE F[',,,'F41L. FIEd....E TO _T. F,I'.:~;URE F'ROPER I NS]"RLLFaT ]; Of,l. I CERTIF"r' THRT :2: I RH F'FIMIL. II::IR P.tlTH THE REL:.!UIREI'"IEt',IT:E; FOR ()N-SITE SE[,IERS RN[:' I.,.IE!_L:~; F:l::.i; SE'T' F'OR]]"I E',"r' THE HLII'qICIF'FILIT'¢ OF i":II",ICHORFtGE. 2: I 14ILL IN:STFILL °rHli< S'¢STEH Il'.,! F. ICC:ORDFINCE !.,.tITH "f'FIE (]:ODE'.:~;. ]:: I UN[:,E:R:~]TFtNIL:, THFIT ]"PIE ON-'.'-~;ITE :-];ENEF'. ?r'L:;TEH t"lR"r' RE~:!UIRE EI'.,ILFIRGEMEi'..!,]" IF:' THE S :1: GI'.,IE[:,: ... , %~/ FIF"'F'L t CF:If'iT Gr'~ERGE' ~"'": ~'~'"] ~:::;" "i." LEGF~L L. 2 E',2 !-! ]: [:,EFIHFt'r' FIL(LL.:5 LOT :~;:~ZE ;;:~:Eu?JE~EI :5(;d. JI::IF;:E F'EE:T TFIE [::,EF'TH Eft: Ffl "f'r~:ENCH OF'. F:']:T ):~-~; THE: D]::~;'f'FihlCE E',ETHEEN THE SUF:F'F:ff:::E ElF' THE: FII'.,IDTHE BOTTOH OF' TF!E ...... '¢ ]:0N '~ ..... F"I ................ DEF'RF:THEHT HT....L. E:E ~;UELZfEE:T TO f:'RO:~:;ECLIT]:EIN. 'FEI ;2EE~ FEET F'OF: FI F'UE',LIE: HEL.L. [::,EPEN[:,Z!'-,I(:~i LIF'ON THE '1-~ FE OF F:'URL '[ '": i.,.IEL.! ..... TH E',"r' THE HUN ]: C ]: PF~L ]: T"r' ElF' RHE H ::: H:[L.L. ;(N~5'I"RL.L.. THE :5'r'~;TE:H ]:N f~E:::::?[:'FIHCE~' !,IZTH THE RESTF,ENr':F; 'J::5 F:EHODEL. ED-F:'t INCL. U[:'E HORE THI::!N 5 PERFORMED FOR: LEGAL DE.SCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMEN'DAL PROTECTION Pouch 6-650, Anchorage, Alaska 99502 :776-2221 PERCOLATION TEST SOILS LOG - PERCOLATION TEST ~¢4 ~ 73 ~ s"'/, ~- DATE PERFORMED: ~-- P s'--' ~ SLOPE SITE PLAN WASG~OUNDWA' "~ ~ ' ~ ~ L . IF YES, AT WHAT '~ Reading Date i 3 PERCOLATION RATE TEST RUN BETWEEN Gross Net Time Time lq: '-t :~ /~../~ FT AND Depth to ~ Net Water 6/¢ I~ Drop /~',b 0 17' z¢ (minutes/inch) ~,~ ?¢ ET ~o,/ ~'" '/'~' G--- F)[:PAH rp,.l[i[,l [ OF Ill]Al I'll A:,i[) ':NdlNO!'-iMI I,i]A L Pi:~O I'IiC]'ION Deceraber 3]., 1980 (?,eorge 2633 Seclusi. on Drive A~chorage, Alaska 99504 Permit {~ 800544 Subject: Lot 2 Block 2 Hideaway Ilills Subdivision A perm:Lt issued by this department for well and/or sewer system has expired as of this date. Permits are issued on a calendar year basis, as stated on the permit, by autnor.~.u, of Municipal Ordinance. If you have drilled the well, a well log should be sent te this department to decument the installatien date. If afl engineer inspected the installation of the on.-sit, e sewer system, please have '[-.hem send us the as-builts for our files. If there are any ~urther questions, please call this effice at 264-4720. Senior Environmental Np{~cia.].is't LNB/ljw eric: Copy of Permit swP/0 5 7 I, [.I-,HI 1 NO. [:,EF'FII-;:TMENT ..... : FIEFILTH RND ENV I ROI'.,!HENTI,:IL. "'RO'I'ECT 101'.,I 8;2'.5" STREET, RNCHOF.:FIGE., FIK. 9~ 31 264-4720 ,Z) IP,II .... :~= .T. -ir" E :3; E-E I]..-.1 E< Ir;.;.-. F' E F-~ IP'I I ,:: 800544 ) FIF'F'L i CFINT LOCFll' 1 ON LECiFIL GEORGE CRA:E;TFI .... '~'- '":"~' ~: .:,~.~. %ELCLIJL~; l I."'Ii'.,! [:,R I ',,,'E SELCLUSION E:,R.,. LO1' '"'' ¢'. BLk: 2. HI[;,EWRY:HILLS SUB l,..O'f' SIZE '5 L'-.' ] -.54 '12 ;:;2 -.':10~]O SI;ilJFIF..:E F:'EET - "-] ' ' - IS · TYF'E OF SOIl_ ME,=,_REF r ILN SYS.,TEM TRENI::H i'"IRXIt"IUH NJHE, ERE. OF BE[:,ROOMS = 'TFIE F:'E.]_ .lIRE:ED SIZE OF THE: $0IL HE, x, URE. FTI_I'~ I/ IlS '7 IE::, lEE F" T' ~-~ == "= ..... ' ~=" 'THE L. ENGTI,4 [:,IHENSION IS "['HE LENGTH (Ii'-,I FEET) OF THE "r'RE:ENCI,4 OF.: [:,RE:AINFIEI...[:L 1"FIE DEI-".'TH OF' R I'F.:ENCI,-I 3R PIT IS TFIE [:,I:=-:TRNCE E, ETLIEEI,I THE SJRFRZ:E OF TFIE GROUN[:, FINb THE E:O'TI'OH OF THE E,'<':FIVR'rIoI'.4 ,::IN FEET.'.,. ThlEI,:.E I'.E; NC SET I,.II[:,'TH FCF~' ]RE. EN_.HE=,. Nx. THE I.:iRE.:FIVEI_ [:,EF'TH IE; THE MINIMUH 12.,EPTH OF GRFIVEL BETHEEI'.,I THE OUTFFILL PIPE,,,_ RNE:, THE E:OTTOH F/F I'HF EXCFI',,,'FIT.T. ON ,::IN FEET). F'ERi',I.T. T FIF'PL I CFINI' HFIS THE F..ESF'L]N'.=] I B I L I 1"¢ TO I NF ]F.'M TH I :F.; [:,EF'FIRE:TH?~T DLIR I NG 'FHE_~' INL:;TF~L.LR'I"IFd'.~ IN:_=;F'ECTIE~NS OF FINY WELLS RD.]'RCEI"4T TC THIS F'ROF'ERT~ FII'.,IB, THE NUHE:ER OF RESIE:,E:N:E'=-; THREIT THE I,.IELL. HILL SER',,,'E. T' ~-,~ N:::~ ,:' ;=:." ":. I ~-,,I ._-:. ~F- E,. L.- IF ][ CT~ ~'-,~ ."'~F, Il ,:~ F:,. lb_ F,:L" ~.-: ~L::". IL.~ ]E If;L" E::£ IE:,, I ' ' .... , "' EIY EFI"'.KI.-ILLIN.~ OF REIt.,IY L-T,'T'SI"EM [,.IITHOUT FINFI!... INSPEC:T:[ON FII'.,II::, HFFRL ,HL. I':,EF'RI-;:]'HENI' HILL E:E :,[.IE, JEL..I TO FRE_:,E..IJl i"IINIMIJH [:,I:L:,TFINCE E:E:I'I.,.IEEI'.,I FI HELL. FIND FtN'T' ]N-'=;ITE':.,Et.,.IPI.~E' "' [' I=,F_=,I-I...'- '-" ' 'Z';'.r'STEH IS; iE0 FEET F'F~R FI FRE. I H1E HELL OR t~['.~ TO 20E~ FEET' FROM FI F'USI_IL-: HELL [:,EPEN[:,ING UF'Oiq THE T'T'F'E Cfi:' F'IJBI_:[C I,.IELI .... M:[NIMUH [::,IS]"F¢.JC:E FROM FI F'RE:I',,,'FITE [,.IEL. L ]]3 FI F'RE'.I',,,'FITE 9EP.tERE: LINE IS 'F_'.~ FEET FIN[) '['O FI COi'"IHI...INII'Y :,EI IEF. L]:NE IS; '~'=;,'._ FEET. OTHEF.: RREf::!UIRE'.EMEN'I"'=:; MI=IY FIF'F'L'T'. SF'ECZFICFITION% FINE:' CCII",I:STRI. JCTION [:,!FIGR. FtMS FIRE H,htiLHE, LE TO II",I:,UP..E I"R.IFERE. ZI",ISTFILL. RTION. I CER]" I F:"r' I'FIFIT 1: I FIM FF. IHILIFtr4:I.,.IITI4 THE RREQUIREi"IE:NT2; F'OR ON-.SITE SE!.,.IERS FIN[:, .WELLS FIS L=;ET FORTH BY THE HI.JI'.~IC]:PI:IL.]:T'T' OF' ;;.2: I I.,.III..L .T. NSTFIL. L THE SYE;TEM IN FICCOR[:,REINCI,F..LIII'H THE COE:,ES. 3:: I UN[:,ERE:~:;TFII'.,I[:, 'I"HFIT THE OI'.,I-SITF' S.;EI.qER S"r'STEH MFIY REt'...'!LI:[I,;~E E:I'.,t[..FIRGEHENT ZF ']*HE RES:; .'1:. [:,ENCE I :.:.'; ~'~:Ei"IO[:,EI_ED TO I NCLI...IE:,E MORE THFff.,I ..%.', E:E['.,ROOMS';. ~F:'F'I,_ I~]' ,~EORE.[:iii,: CF..O'.'.-'STFI ............... L./. '..., . [: ) , ? .- r:, ..... 7..' 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 GENERAL INFORMATION Complete legal description Lot 2;'B10cE 2;.'.H~deaway H~S' Location (site address or directions) 2633 Seglusion Property owner Mailing address Lending agency Mailing address ALASKA U.S.A. FEDERAL CREDIT UNION Day phone P.O. Box 196613 Anchora_q&, AK 99519 786-2709 Day phone Agent Ad d tess Day phone Unless otherwise requested, HAA will be held for pickup. 'NUMBER OF BEDROOMS: 5 N TYPE OF WATER SUPPLY: Individual well Community well Public water XXX NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. · ·, XXX .~ ,. If community wastewater system, provide written confirmation from State ADEC, attesting to the legality and status of system. NOTE: 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 system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verifythat 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 s & $ ENGINEERING Address Engineer's signature b~"'- ~I~",~%~.'~ DHHS SIGNATURE '~ Approved for bedrooms. Disapproved. Conditional approval for · bedrooms, with the following stipulations: Additional Comments Date TheMunicipali(y of An~h0rage Department of Health and Human Services (DHHS) issues Health Authority Apptovai Certificates based only upon the representations given in paragraph 5 above by an independent r, rofessional 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 an¢ 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. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:/-07' 2_ /~_~ ~ /-//b~EAf,,,J,~l''/~//_J..~ Parcel I.D. A. Well Data --/k.)O/LJ~ ~ ,/'~L)/,J/¢__.[/~.~(.._ ~.,~/~'7-)c?//.~ ~'c¢¢S~_.~-,/~1 Well type A Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to FROM WELL LOG Nitrate Driller Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot ~ OO ~ Y'- Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform Date of sample: .. DATA Date installed / '2_ / / 7... / Cleanouts(~N) '7/~ High water alarm (Y~. Date of pumping ~ / J g.p.m. AT INSPECTION ;On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Other bacteria Collected by: .g.p.m. SEPARATION DISTANCES FROM SEPTIC~TANK TO: Well(s) on lot ./(./b/,/C~ On adjacent lots To property line ,// / Absorption field ,.~.,~' Sudace water/drainage /'~_?F~ 72-026 (3/93)' Front CONTINUED ON BACK PAGE Foundation Water main/service line Tank size Foundation cleanout Compadments Depression Alarm tested (Y/N) Pumper ~'~ C. LIFT STATION Date installed Size in gallons Vent (Y/~ /tJ 0 "Pump on" level at High water alarm level Meets MOA electrical codes~)N) Manufacturer Manhole/Access ~)N) '7'"~._~ /t "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot ~o,,t)~. ~OJ~/'- On adjacent lots Sudace water D. ABSORPTION FIELD DATA Date installed ~" / Z_ ~/ ~/ Length l') ~' ! Width Total absorption area / '~.~_.~ ~ Cleanout present Date of adequacy ,e. ~/~/~ Results ~ail) Water level in ab~tion field before test ~ ~ Soil rating (GPD/FF) Gravel thickness Total depth Depression over field (Y~.)) ~" (/~/L/'&~') Bedrooms for After test /'~"~'~ ;~'/ Peroxide treatment (past 12 months) (Y/N) /C~O~/~ /~ ~/~/ If yes, give date ..-~---~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot/,)O,U~:~ /~,~-~L-_-~.~ On adjacent lots To building foundation ,/~ ' On adjacent lots ~ Surface water / L?L") Curtain drain Properly line To existing or abandoned system on lot /O ' Cutbank ~'~) ~''~ Water main/service line ['©/'~- Driveway, parking'vehicle storage area .~-/''/- E. ENGINEER'S CERTIFICATION I cerb'fy that I have checked, verified, or conformed to all d HAA guidel/nes/n effe_ch 5 & S ENGINEERING " " Signature 1 :',~'~,~ ~.~,a. ,~,.,,~, ,,,,,, ~,~ ~ ..a-ha - ' ,- Date .:.: :' ,..:: 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 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # 1. GENERAL INFORMATION (Must be completed prior to submittal) (al Legal Description (include lot, block, subdivision, section, township, range) Lot 2; Block 2; Hideaway Hills Subdivision Location (address or directions) 2633 Seclusion Drive (b) Property owner Alaska USA Mailing Address ~,O, '~¢?-.. la t¢~."5 (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (el Mail the HAA to the following address: (or check here ~(if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING Eagle River, Alaska 99577. 2. TYPE OF RESIDENCE Single-Family [] Number of bedrooms 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 ~x 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. 72-025 (Rev 7/88) Page 1 of 2 5, ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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 S & S Et4Gd4F.~-RtN6 Telephone 17034 ~agle River Loop Road No. 2~ Address ~gl. River, AlaSka 99577 .Approved Disapproved Conditional Terms el Conditional Approval ,,/L''/¢1///~-~'-~ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 DHHSdonotconductinspections or analyze data beforeacertificateisissued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Heallh Authorily Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: Well Classification Well Log Present (Y/N) 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 To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ~ Date Completed Depth of Grouting If A, B, C, D.E,C, Approved (Y/N) Yield Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) · On Adjoining Lots ~l~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date B. SEPTIC/HOLDING TANK DATA Date Installed \~--- ¢_~t Size Standpipes (,~N) '-,/ Air-tight Caps Depression over Tank (Y/~ ~'J Pumping/Maintenance Contact on File (Y/N)/ Holding Tank High-Water Alarm (Y/N) No, of Compartments '7/ Foundation Cleanout ~) '7/ Date Last Pumped ~ - ~ ¢/~./ ; for -- ' / Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well ~ 1.+~ To Building Foundation To Property Line 1 \1 To Disposal Field To Water Main/Service Line To Stream, Pond, Lake or Major. Drainage Course Comments ~ ¢~,~d ~ 72-026 (Rev 7/88) Fronl Page 1 of 2 C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata ,.~..~,:~ ./.,/~4.-.- Type of System Design Date Installed '¢~ - ~ ~ ~ Length of Field t,~ '~"-- Width of Field ~... S- ' Depth of Field '7 t ( t I4~"Ol.~Z~l~-'~ ) Gravel Bed Thickness ~ r Square Feet of Absortion Area \~ ~--'c;:> ~:' Statndpipes Present ClaN) "'/ Depression over Field (Y/~I~ ~ Date of Last Adequacy Test '"/ Results of Last Adequacy Test ~~-~1F"¢~'~ "- ~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ~ I ,'r- To Property Line ~, To Building Foundation t. c::, To Existing or Abandoned System on Lot \ o~ ~ ; On Adjoining Lots To Water Main/Service Line t. ~ To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course \ 4~=c:::~f ,9- To Driveway, Parking Area, or Vehicle Storage Area \'-/! Comments ~'--,[~ ."~¢--~.~~ ~-"-~/-~,~ ~ "-'-~--~"'F~. D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for ~ Meets MOA Electrical Codes<CighN) Comments Dimensions 0~.~, Manhole/Access (rC~N) ~ "Pump Off" Level at ~ ~ Vent~N) ~ Pumping Cycles during Adequacy Test, '7' **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in e,f~t~[":~i.~'e'~C,.ate of this inspection. Company 110~4 River~ Al~kn 99~7 Eagle Date cei.t.o. Date of Payment 7 ~/¢ ~ ~:~ Waiver Fee: $ Amount: of , ment a) legal [~scription (include lot, block, subdivision, section, t~mship, range) Location (add, ess or directioas) b) Applicants Nar~ Applicants Ad.:ess ~[ 2 d, 2: :~ '; ' "< ' Telephone 2' 2: '/- ' :'/" ~ ," c) Applicant is (check one) lending Institution (d) Lending Institution __~/'::,/c2/~ <e> Te ].e phone Address ,~j, %'"o ~// ~ / ., Telephone 2. '!yi}e of ~esidenoe Single-ffamily L->~' Number of Bedroc~a Other < de scri.,%e > 3. Water Sup,pl~: Note: If c~rmanity well system, must have wit. ten confirmation f~om the Stae: Depa~.~nent of :~vlronnr~ntal Conservation attesting to tFe legality and status. Is the well adequate for the number of bedroons specified in this HAA Onsi'te ~ B:blic [~ Cc~munity ~ Holding TauJ~ ~! Is the wastewater disposal system adequate fsr the ~mber of bedrooms (Y/N) [Pag~ 1 of 2] 2-15-84 5. E___n_qineerin(..L_F_i_rm___~__o_v.i_.di_~ng~Ins~ctions, Tests, ~nta and Information I certify that I have checked, verified, or confor.~ed to all MOA ~iAA Guidelines in effect on the date 9~//-~k~ is ~pectioh. Signed z ,-W/~ ~>/ Date ./ Signed by .... Date ( ENGINEER SEAL) 6. DHEP Ap_p, ~gv_~' Approved for ~ bedrooms Terms of Conditional Approval Conditional Tbs Municipality of Anchorage Department of Pmalth a[~.d Environmental Protection does not guarantee the continued satisfactory performanoe cf the water supply and/or the wastewater disposal system. %his approval indicab~s that, as of the validation date shown alive, based on the. data and infornuTtion fur~ished by a~ engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional for the number of bedrcxans and ~:ype of structure indicated. ( [YrlEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] 2-15-84 C0 ALSOP~rION FIELD DATA Soils Rating in Absorption Strata Date Installed ~ ~//~/ Width of Field Cp< 3 ~2" Square Feet of Absorption A~ea ~.~$--.. . Type of System Design Length of Field 12~ /~ Dep~J/ of Field _~ '~ / Gravel Bed Thickr~ss ~ Standpipes Present (Y/N) Depression over Field (Y/N) Results of Last Adequacy Test ~3'~/ ! Separation Distance fr(~ Absorption Field: To Water-Supply Well /i///~ To P~operty Line To Building Foundation ,~/{- /O / To Existing or Abandoned System ca Lot /p//7 ; On Adjoining Lots _~o7~ z~g~. To Water Main/Service Line /~ ~ To CutbarJ¢(i__~_p~sent) . To Stream/Pond/Lake/or Majo~ Drainage Course /~ To D~iveway, Parking Area, or Vehicle Storage Area __~_ Date of Last Adequacy Test 3> ~/~ __ De LIFT STATION Date Ip~ ~alled~ Size in Gallons ~'Pump ~" Level at High Water Alarm Level at"// ~ z-//z' Dir~nsions /~o2d. /~f~ · Manhole/Access (Y/N) .~...~ "Pump f~f" Level at '~' ' Tested for ~ Pumping Cy. cles during Adequa~f 'rest. Electrical Codes(Y/N) /~ Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, o~ conforr~d to all MOA HAA C~idelines in effect. on the date of this inspection. Signed ~//~Y Company ._/.~>--~'~ ~/~-~ ~ ~ . KB1/dL/s [Page 2 of 2] ENGINEERs 2-15.-84 MUNI'CTPALZq~r'Y OF ANCJ-']OI~A. GE (MOA'I DEPT. OF HEALTH & · ENVIRONMENTAL PROTECI'IOJ~ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well Classification Well Log P~esent (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances frcm Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water SampIe Collected By Water Samgle Test Pesults APR e', ,., h¥,'7~-- .RECEIVED If A, B, o~ C, D.E..C. Approved(Y/N) /~5 Date Corr~le ted Yield Pump Set At Depth of Grouting Sanitary Seal on Casing (Y/N) Depression A~ound Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date '/ (/'/. "~ ,' ",- · , '. >.// Be Date nstalled ' Sizew of C a= nts Standpi~s (Y~) ./~j Ai~-tight Caps (Y~) ,~/ Foundation Cleanout (Y~) ~p~ession o~ Tapk (Y~) ~ Date ~st P~d P~ing~intenan~ ~n~act on File (Y~) ~ ; fo~ Holding Ta~ High-Wate~ Ala~ (Y~)~ Te~ra~y Holdi~ Tank Permit (Y~) ~p~ation Distan~s ~ ~ptie~olding Tank: / TO Water-Supply ~11 ~ To ~ilding Foundation ~ To ~0~rty Li~ // / ~ ~.~. To Dis~sal Field ~ ~ / To ~ter Main/Se~vi~ Li~ ~:~,,~ :/~ To S~, Pond, ~e, ~ ~ajo~ ~aina~ [Page 1 of 2] 2-15-84 L~A'I~E RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR /ViUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT; OF HEALTH &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECJi]tC~I~ONMENTAL PkOTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTALSANITATION DIVISIONAPR 2 8 1981 Telephone 264-4720 D rEl /r REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~~ ~ DIRECTIONS'. Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY O~NER ~ ~ PHONE MAILING ADDRESS PROPERTY RESIDENT (If differen~ from above) / PHONE 2. BUYER r ~ PHONE MAILING ADDRESS ~ 3. LENDING INSTITUTION ~ PHONE I MAILING ADDRESS MAI~I NG AD.ESS I 5. LEGAL DESCRIPTION STREET LOCATION 6, TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One ?~.-Pour [] Other I~/SINGLE FAMILY [] Two ~J Five [] MULTIPLE FAMILY [] Three [] Six 7. WATER SUPPLY [] INDIVIDUAL* * ATTACH WELL LOG. A well Icg is required for all wells drilled p COMMUNITY since June 1975. For wells drilled prior to that date, give well UBLIC UTI LITY depth (attach Icg if available;) 8, SEWAGE DIS/~OSAL SYSTEM ~ INDIVIDUAL/ON-SITE** ~(~' [ YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY ~lP_~_~ ' ~~ ~7~. ~C~'~ ~"~.LJiJ- ~) 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 [] INDIVIDUAL 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 []HoldingTank Size: If Tank is homemade SOILS RATING give dimensions: __ TYPE OF TANK ' ~'[~ER Absorption Area to n [~;~//APPROV E D FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED ,?'? DATE BY ,~ DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAG~ PROTE~Ti~EPT. OF HEALTIt & DEPARTMENT OF HEALTH & ENVIRONMENTAL ~'N~'YI~ONMFNTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION SEP 2 6 1980 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~IL~J~Jl LVI~L~ DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) J .) PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION I PHONE MAILING ADDRESS 4. REALTOR/AGENT I PHONE I MAI LING ADDRESS 5, LEGAL DESCRIPTION s=~= ~oc~o~ P ' 6. TYPE OF RESIDENCE NUMBER/~F~BEDROOMS ~ One ~ Four ~ Other ~ SINGLE FAMILY ~ Two ~ Five ~ MULTIPLE FAMILY ~ Three ~ Six 7, WATER SUPPLY F-I 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 ~ INDIVIDUAL/ON-SITE** l ~'~--~"~ YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, 72-010 (Rev, 6/79) 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 [] INDIVIDUAL 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/Holdin[~ Tank IAbsorption Area Sewer Line I Nearest Lot Line WELL TO: I Absorption Area to nearest Lot Line 5. COMMENTS [] APPROVED FOR BEDROOMS I~ CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY ./ SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~ PERCOLATION TEST Pouch 6-650, Anchorage, Alaska 99502 276-2224 SOILS LOG - PERCOLATION TEST );/~ ~ 7 ~ - _CY/'z PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 5 6 7 8 9 10 ~11 ~3 14- 2O COMMENTS PERFORMED BY: WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SLOPE SITE PLAN ~ ~ ', ::iL ...... I ! I'-' ~,~ ~-~ : ~ 'x,~ Kt,_( > · L ' ' ' ~ :-~ ' ~ o Gross Net Depth to Net Reading Date Time Time Water d~ 1 Drop / ?-~_T /~. ~' ~ / -~,o PERCOLATION RATE '/'/~-') (minutes/inch) TEST RUN BETWEEN ~ FT AND /'~(2 FT DATE: 72-008 (7/76)