HomeMy WebLinkAboutHIGH HOPES LT 3High Hopes
Lot 3
#015-082-14
Nov20 20 11 42.E An,,hornf b'Veil & Piinp Sel
X07 430742 n.1
C
Deveioprneni Services Departrrent PhC7l7@: 90-11-343-7,'-;04
On -Site ''Water & wast, =ryate Sc-�tzofl ax: 907.-343-7997
t EA1 Drilling Permit Number:
Parcel Idea dficaatien Number- D (_ -.082_ 1 `i
Legal TJescriptiun -- Block
Pump Installation Date:
Date of Issue:8_4;,-.716
Properq- 0.4-ner Naaarie & Address:
Puralp brake f'prh Be -low lop of Well Casin(_r: ,fit feet
Pasta_r---
PUIXP Mode),
1'0111p Size-
Pitless Adapter Burial Depth: _ 3 5— ___ reet
Pid ess Adapter Manufacturer's Narme:
Pitles, Adapter Insaaller:
Well Visinfeciedi U, or' £`oaQ leiion? ❑-r-t's q- tido
Method of Disinfe4xlaaa:
omenta ants:
PT!Ihp Installer aq—ie:
339 cast 76th Avenue
AK 9951$
�-hor e: 907•243.0740
4lanliz Address:rix' 9117 243-0742
City.-
Mate:
Atteatiusn: The puaip installer shall paiti4.ido a pur*:p :a�seal.iatiort log to On-s,tc xithin -10 days ofpuanp install:zdon.
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 ANLL/OR WEI.I_ INSPECTION REPORT
NAA9 ^� PHONE FW
UPC, RADF
MAIL[ NG ADDRESS
LEGAL DESCRIPTION
l� i I-�_6_!��_.-
LOCATION
NO. OF 1.3_74�jj-D,�ROOMS
-
Well /�u -Absorp " r],a r�a
DISTANCE TO:(/r- — (O/
Dwelling o
/
PERMIT N
--
f- zManufacturer
Maten
No, of compa tments
W 4
N
_
. capacity in gallons Inside length
ILiqIF HOMEMADE :
Width
Liquid depth e
Q �
Well � Dwelling
2
02
Manufacturer -_--- — — -- ----- - ---- - l Material --
-Liquid capaci gallons
PERMIT NO
j 7
w
_ Well ^ Tl
DISTANCE TO:
Fount anon Nearest lot line /n
-
a Z
��w
No. of lines Length of each Iii e
)))
�."_--�
Total length of lines drench (it
inches
Distance betweery ,
i
y
Top of the to finish grade
—`�_—-----_�
Material eneath He
indles
"total effecti nbsoration area
ui
Length Width
Depth -i-
PERMIT NO.
Q N
fi
Type of crib
Crib diameter
Crib depth
Total effective absorption area
t51
to
N
Building foundation
DISTANCE TO:
Well
Nearest lot line
Distance to lot line I PERMIT NO.
Class
Depth
Driller
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
�r
OTHER
—
{�
PIPE NIATERI S
SOILI"EST RATING
--
-
--
INSTALLER�
REMARKS
— ---- -- -
r�
I
APP VED DATE LEGAL
(�
I
[.1 E Pf"I R' H, I E N T .-JEALTI-I AND EN %.'I RONMI.E."N "I" FIL
'",FJ _1 Tf,..., E E". 'T.. ANC-11C)RACiE., FiK. GC. -1
-tO
IIA -11: k—, 9.—.. f�:o PA 3. TAE. U.-JIF-'P, 1, -*:u FEE I--" If'.1 I ""ll"
Pf"'Plell"I" NID. r%, 800.�.xl .1
Lus, 9
A 1:�;; I::, LI U A 11TI UEE'RI-11-1.) j:::i VINV` ,;,910 2-4 _3
LED".:iAL TJ,2NP,.N L23 I LOT SIZE 'c-.'_l7l'80Ci SC' MARE FEE']"
8, 1 q,
::::Oj,' L 11 iIFJ",TIOP.,l SY.".5TEM IS: TRENCH
/
IVI I'll IMBER, (.IF BEI*.'.,jROOMS -.1 RFITIJ.115, C.SC! FT,.o'BR)= ')'b_
THE ...,'IZE OF' THE SOIL FABISORPTICiN 1-:51rISTEVI 12"
A, J.. L.._ I E . ---' P-4 T - 9-- 9 F=•j 0-0" F_—.
LENGTH DIHEIISIcl.,i is' THE LENG"l-H (It. -I FEE -T) OF THE TRENCH OF,,
DEF'TH OF F -i TP,ENCM CiP., PIT IS THE Cil.kSTANCE BETWEEhl THE EURFACE OF TPIE
GROUNC, FINC, TFIE Er C)"I""I"Ol-I OF- THE P41,CAVATION r.'IN FEE.T').
J'HEI-,-.,E 1.5 NO SET HIEll'Id FCIF.' TRUICHE-C'..
GRA%EL DEF,TH IS THE MINIVILIFI DEF,7*11 OF 13RAVEL THE OUTFALL F' I FV
Aill,') TT,IE F-M-i"'Tot-i CIF THE E'e,::CA'-,4FIT ION f"IN FEET).
-F F --i PA K I -,a". F-' I t -5 Q- C- F=i I.— L_ C P-4
ll'�P, El"'. Cil"*H LJ J.' F -'-A ka' 1- 1 C
PERMIT f"iPPLICANT HAS THE RESPONS IB' ILI I"T' TO INFORM THIS DEPARTMENT DUR1110 THE
I:Y,I:.:;'Tr�l_.L._I=i"rIC:LCYa I THE
JI,.4sFlEC:TIOhIS1 '-'F ANY WELL,. AI'.JAC,EN'T 'TO '*THI'S F',RC"iPEF'_TY AP'4Cl
[.1UMBER, OF RESIC-ENC:ES THAT THE WELL WILL SERI,,.,E.
..I_' U.."ll cd w." ;ZP., .-,a I PA !E. F', F." N*_-". -1*- 1 C -P PA n F-,,,, IEK F.M. E:.:.'. G"."! 1_11 1 Fe.
OF ANY S'l-"-,TEI'l 1,117"HOUT FINAL 1h)-`51"'ECTION AND APPROlylAL BY 'I"HIS
IdILL F.:E SIJE:JEC:T TO PROE..'-ECUTICIP.J.
I.l':lI'E1fAI,-JI-:E BE"TkIEEP-4 fl I. -R. -ELL ANE'l ANY ON --SITE SEIdAGE [) I'S PCv:.:.*AI,_ Sli-12,'"I"Ell 15
I -'EhID'
J. C FEET FCR A FF,IVATE WELL Of',', 150 TO 200 f7l,"."ET FROM A PUBLIC WELI DEF I
LJPCN IHE IYPE OF WEI...L.
HIP -411,11-111 C,-,lI,.;TAhICE FROM A PRIVATE'* WELL 'TO A F'RIVATE SEWER LINE I'S, 25 FEET AND
TO FI '..;Ei.-IER LINE IS 751 FEET.
I. -JE: I Ll., LC)Cis-': ARE REQUIR.Ef) ANC, MUST BE RETURNED "TO THE DEPARTMENT WITHIN --.,-'0 [)AY
OF THE I,dEI.J_. C:0I'-lPLETION.
- F lS FIRE
OTHEF. REI]!I_lIREilEI,-J'I"S PlAY APPLY. SPEC'I FI CAT 10NS IND C.:ONS"TRIJcTD"DN DIAGRAt
f-ll,)ATLABLE ]"0 If-JSIJRE PROPER INSTALLA"I"ION.
C_. Imo" Irl WHE. F -' F-." 2 ': �l j- RD
I CE-RI-IF"r' THAT
1: 3'. AM Ff"IMILIFIR lkll'TH THE F-,EQUIF:EPlENTS FOR ON --SITE SEWERS AND WELLS AS SET
'E.
FOP.1"l-I FBITI 'THE 111-INICIPF-d-ITY (IF' ANGFIORAI
I kIILL INSTALL ')"HE' SYSTEFI Itl ACCORDANCE 1411"l -I 'THE DICE,i".
I 1_IkII."-EP,STAND "THAI' THE ON—SITE SEWER SYSTEM I'lAY REAUIRE ENLARGI NPIT IF THE
I
IS k,EMODELEC) TO INCLUME MORE THAN 4 BEC -1R ?I j
RESTClEhlC':E t J
AFT:T. I CF11,11" FJERALD A VI I,.J
SI lzz, 1-kC 0
Df
❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE7//
• +.d'.; DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
14
15
16-
17
6 17 .� eD•@�i'Ap�y��
�. 0s A I-
AMP� •o •MHo•/•e° i.�d 4
18—
,.R •° iwt
19 �#s "•o
a• a n i @U@•o•@• °
.9@0 109iAI•F°PYe°vo@90@•@@s•�0
20 NO. 1732-E '
s1'' °•. June 22, 1968
DATE PERFORMED: r`��.��t-/ 3z��
SITE PLAN
N
s
L \
0
P
L
Reading
Date
`.'�iZi2I ✓ ��-') ��
PERFORMED
FOR:
T
% L
`_—
LEGAL
DESCRIPTION:
,,rr f SLOPE
t-�'-' I �.�Y� t
DEPTH
(FEET)
2
3
�1
4
� 7 .
6
F 1
7
8
f (�
I f wl
9
10
11
WAS GROUND WATER
N
ENCOUNTERED?
12
IF YES, AT WHAT
13
DEPTH?
14
15
16-
17
6 17 .� eD•@�i'Ap�y��
�. 0s A I-
AMP� •o •MHo•/•e° i.�d 4
18—
,.R •° iwt
19 �#s "•o
a• a n i @U@•o•@• °
.9@0 109iAI•F°PYe°vo@90@•@@s•�0
20 NO. 1732-E '
s1'' °•. June 22, 1968
DATE PERFORMED: r`��.��t-/ 3z��
SITE PLAN
N
s
L \
0
P
L
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
21�
PERCOLATION RATE_ / 'I-- (minutes/inch)
TEST RUN BETWEEN FT AND _L® FT
COMMENTS
+�ew�wa
t /� _ I�
PERFORMED BY: f_?l'1 TT ��I 1 --' Vi C— CERTIFIED BY: - DATE:
72-008 (6/79)
P -Boss ycrr�sl���r��F� � az�� D ➢ Q '
13�l�1N'!'fl.l
SIX INCH WATER WELL. DFRILLED AND CASED OUT TO THE DEPTH OF
DRILLED AT TI --1E. RATE OF
PROPERTY OWNER
),1 k-.,,
LOCATION OF WELL SITi_— �____
DRILLER
WELL LOG:
( 3 j_ucl
PER FOOT.
Pon -d 3),'4 ,c3,3;
.23,•..
-- = i i
67—, {?`: t :i./J;. (I�.:CI- _�(r✓1-(.{. �JU�I {.�/P.'.'� C(.Qlr CttL�J 40.'q Clt.CSU"e�.�__-_
g ood. can _w cr,�utr ( Jute 4 -4rvi_U arzoruvL o -z'__ iand__-
�ti ._�;5a, t .a,io l �? �tf %L,e .Sc�bn eJr� ✓.Ze 1 uG r� �holl Cd -be / r o
ee,t of t1;i�e c a-wn �i-nuc 2n" ccs L �.a
CJD-'`. (ice :'i;Cif�'. ,ill C(: `�(1 �'.C',-7. '%'�p,(. ii t7 ��,:1843„00
.GD4 Q,”-�.L(. .Se2� : „^�1-� (IO MUNICIPALITY OF
DEPT. OF = ANCHORAGE
i� � .
ENVIRONA/,ENTAL
7ECI ION
RECEIVED
COST INCLUDES ALL LABOR AND MATERIAL, FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLETO RAMPART DRILLING WORKS FOR THE SUM OF t'>8650 00
THANK YOU VERY MUCH.
BERNIE CLAUS OF RAMPART DRII LING WORKS
DATE-3ji-l_Ic Zt,2_c `1 cf_ CO C(
SERVICE CHARGE 0 1' 1!12.% PER MONTH WILL OE' ASSESSED ON PAST" DUE ACCOUNTS.- ---__.
Municipality of Anchorage
Development Services Department :'�'"
Building Safety Division`'
On -Site Water and Wastewater Program „ , 71
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
ww907) 3 3-79 nsite
(907) 343-7904 /A q ,(q
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL I
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 015-082-14 COSA # HA OCIO IST
Expiration Date: qlldlm
1. GENERAL INFORMATION
Complete legal description High HoaesSubdivision Lot 3
Location (site address) 6940 E 9911 Ave Anchorage, AK 99507
Current Property owner(s) Gerald and Colleen Vnk Day phone
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
6940 E 99th Ave Anchorage AK 99507
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems 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. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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 Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) In compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Engineering Services, LLC Phone 272-8218
Address _P.O. Box 102954, Anchorage, AK 99510
Engineer's Printed Name Steven R. Pannone. P.E. Date 5/1912009
Engineers Comments: In conducting an adequacy lest, I attempt to provide a Thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions
encountered at the time of the test, and separation distances measured to readily identifiable features.
The operational life of all wells and septic systems depend on the local soil condition, ground water
levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of this system. All systems eventually fail and
satisfactory test results do not guarantee future performance or the system, nor do they guarantee that
there are no hidden defects or encroachments. PLS can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the h10A DSD. The content of this report is for the sole benefit of the owner listed
above. Any reliance upon or use of this report by any other person or party is not authori7.cd nor will it
confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for —I bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
jz • WATER AND : Fn-
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Ni�ate Advisory
X Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other _
Original Certificate Date: l�
01
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: High Hopes Subdivision Lot 3 Parcel ID: 015.082.14-000
A. WELL DATA
Well type P It A. B, or C provide PWSID N _
Date completed 11111980 Sanitary seal (Y/N) Y
Total depth? ft. Cased to eft.
FROM WELL LOG
Date of test 11111980
Static water level 40 ft.
Well production 8 g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate 2.87 mg/L
Arsenic:. ND ugA Date of sample: 411412009
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 12+ in.
AT INSPECTION
411412009
49 ft.
3.5+ g.p.m.
Other bacteria S colonies/100 mL
Collected by: M. WEHR
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Greer/Steel Date installed V2311980
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 4113/2009 Pumper A+ Home Services
C. ABSORPTION FIELD DATA
Date installed 319!2 1980 Soil rating (g.p.d./fe or ft2 bdrm)185 System type Deep Trench
Length 47 ft. Width 3 ft. Gravel below pipe 8 ft.
Total depth 12 ft. Eff. absorption area Lft2 Monitoring tube Y Depression over field N
Date of adequacy test 411412009 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 62 in. Water added 600 gal. New depth -62 in.
Elapsed Time: 150 min. Final fluid depth 59 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date Installed
"Pump on" level at _ in.
Datum
Size in gallons
"Pump off"level at _ in.
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot 110
Absorption field on lot 100+
Public sewer main 100+
Sewer /septic service line 25+
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots 100+
On adjacent lots 100+
Public sewer manhole/cleanout 100+
Holding tank 100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 10+
Absorption field $+
Water main 100+ Water service line 25+ Surface water 100+
Wells on adjacent lots 100+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 25+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that I have determined through field inspections and
review of, Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone, P.E.
Date 511912009
COSA Fee $
Date of Payment,
Receipt Number
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
4917
K
Steven R. Ponnone!
0-1K No. CE 8149 f �1 i
In.
LOT 2
0
M
E. 99th Avenue
— —rE — —
S89°57'42"E 219.63
0
M
8240R
ri
S89°56'40"E 219.45
TRACT B
VALLI VUE ESTATES
4E OF. A44 lj
*: [�9TH�3 /J
% Fred l'!c'a:ka
/ Na. 3255-S
SCALE: 1"= 30'
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT ARE NOT SHOWN HEREON. FBm 09-2, pg 49-51 BE
iJ
AS -BUILT NO CORNERS SET THIS DATE
6
ca
7
r �
OZ
O
SCSRefq
1091445001
Client lame
Pannone Frig. Stv.
Project lame/M
I ligh I lopes Lot 3
Client Sample ID
1ligh I lopes Lot 3
Matrix
Drinking Water
Sample Remarks
Parameter Results POI.
Metals by SCP/MS
Arsenic ND 500
Waters Department
Total Narate/Nitntc-N 287 0 100
Microbiology Laboratory
Colony Count 5
Total Coliform 0
Fecal Coliform 0
Printed Datdrime
Collected Date/time
Receised Date/rime
Technical Director
04/24/2009 16:56
04/14/2009 10:53
04/14/2009 11:40
Stephen C. Fade
Allowable Prep Analysis
Units Method Container ID Limns Date Date Inil
ug4.
GP2008
C
(<10)
04120'09 04122/09
NRB
mg/l.
SM20450ONO3-F
It
(<10)
04123/09
1D7.
col/100mi. SM20922211
col/100mi. S\120922213
col/100mL S%120922211
A (<200)
A (<I)
A (<I)
04/14/09 DI.0
04/14/09 DLC
04/14/09 DLC
Page 1 of 1
Crewdson, James A.
From: Steve Pannone [steve@panengak.comj
Sent: Tuesday, June 09, 2009 3:18 PM
To: Crewdson, James A.
Cc: Laura Pannone
Subject: High Hopes
Attachments: High Hopes 032.jpg
Jay,
I am writing in response to your "pink Sheet". The tank is located on the northeast side of the house under a paced area. I
installed treated 4x4's staked to the ground around the tank to prevent it from being drive upon. Sec attached photo.
I believe this addresses your concerns. Please call if you have any further concerns.
Steven R. Pannone, P.E.
Pannone Engineering Services, LLC
(907) 272-8218 Office
(907)272-8211 Fax
(907) 227-3522 Cell
6/10/2009
Time Time
Date
Date
Date
_
lr —d 0 o
Inspectur
Inspector
Inspector
Comments
GC�hiD�La.�At3�ravaf .=f
k{I
}} II
(P)pp
a
Date Sewer Installed
Permit No.
Septic Tank Size .
Uf m7
Holding Tank Size
Soils Rating
Well To Absorption Area
Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner i e �ep / /7���� Phone
Mailing Address ,/ i
c/.
� Af
Boyer 'o 0
Address 3 hr
r
_
Lending institution-, _y - /� Phone
Address
Realty Co. & Agent /J Z✓ Phone
Address
Legal Description p i 7 fJ ho
j P e
Street Location
Type of Residence
Single Family
0 Multiple Family No. of Bedrooms
_❑ Other
Water Supply
Individual ATTACH WELL LOG. A well log is required for all wells drilled since June
Community 1975. For wells drilled prior to that date, give well depth (attach log if
_❑ Public Utility available.)_
Sew Disposal .�y
WRgIndividual GJ0_�
Year Individual Installed:.
❑ Public Utility When Connected to Public Utility:__
❑ Hoping Tank
NOTE: THE INSPECTION FBF MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
_
�J
q l
LLn
DATE RECEIVED
NUMBER OF,BEDRO MS
INSPECTION APPOINTMENTS
(UA
TIME
1W Three ❑ Six -
TIME
TIME
DATE
since June 1975. For wells drilled prior to that date, give well
DATE \
DATE
INSPECTOR
-
INSPECTO
INSPECTOR
MUNICIPALITY OF ANCHORAUr
MUNICIPALITY OF ANCHORAGE DEPT. OF fl2+LTI1 &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE(M)ANONMENI'AL PforEC11ON
825 L Street - Anchorage, Alaska 99501
®
li
! 1 r���
ENVIRONMENTAL SANITATION DIVISION
Telephone 264.4720 -
RECEIVE
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.
1. PROPERTY OWNER
-
PHONE
MAILINGADDRESS
-
PROPERTY RESIDENT (If
different from above) - -
- PHONE
2. BUYER
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION -
PHONE
MAILING ADDRESS
4. REALTOR/AGENT
PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION/ r
STREET LOCATION
^�
�J
q l
LLn
6. TYPE OF RESIDENCE
NUMBER OF,BEDRO MS
SINGLE FAMILY
❑ One [ X Four 0 Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
1W Three ❑ Six -
7. WATER SUPPLY
;kI INDIVIDUAL*
*ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
B. SEWAGE DISPOSAL SYSTEM
-
INDIVIDUAL/ON-SITE** _ U 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
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
El PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL T0:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
[APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
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BY