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Home My WebLink AboutHIGHLAND TERRACE #5 TR 1-B MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEAl_TH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT TPHONE --~NEW MAI LING ADDRESS LEGAL DESCRIPTION ~OCATION ~' DISTANCE TO: IWell / O0 ~ / Absorpti/~;a DwelHn~-o , ~ Z Manufacturer Material ~ Liq. capacity jrt gallons I ............. I Inside length ~. Width ~-~ / heel DISTANCE ~/ /Well ~ ~ ~datio~~ I Nearest lot li~~ ~- ,+ .:o [ ~- -S 0 Total length of li~j~) I Trench width~ d~ / ~ ~ inches NO. (~>B EDROOMS ]No. o.~compartments Building foundation DISTANCE TO: Liquid depth PERMIT NO. -Ei{quid cap'~[ty in gallohs~- PERMIT NO~/ Distance bet~veen lines Total effective abs. o[ption area Well DISTANCE TO: t- t ~._)(-D ' No. of Hneso Aec- Length of e?c,~p, ine Top of tile to finish gradeL[ Mater iai beneath tile ~ ~ ' . ~ inches Length Width Depth PER ~1~ NO. ~_~1 qT6Type of ri~/ ..... ~ ' Well~ia met~/~~ ~ ~:Cril~ depth Bu(Idi~ou ndatio/ ~ "'/ [~ / ~ II T°tale~est~eff~tiV~lot line'~bs°"pti~°'~rea/'~ /(/_~.-/~ "' -[~.~ ~ NCE TO: ---- n~ ~ ~ I Distance t0 lot line/ --~~/--- ~ Sewer line I Septic tank ~ Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS APPROVED DATE LEGAL F:It:::'PL. Z CFI!",IT t~:i',F:LI(;::E: H. MFITTSO!',I I..EIE:RT ]: C)I"-! C I C:UT'T'I:::! I'ff::!'¢ THE I....E!",!GTI'"! [:' :[ !"IEN!!~, I Oi",! :I: S '1"1'"tli:~; L. IZhlCiiTH ':: [[ N FEET ;:1 I]IF THE; TI:;;J!i:I',ICI'! C)R [:'RI::1:1: .k!F ! ELI>. 'T'HE DEPTH ElF FI "I",~;%!",IE:H O1:;~; I::'!T Z:~.!; THE D!STFII",ICE BIETI,.IEE!'4 'T'HE '_;.i;URFFICE O1:::' T!'"fE EiI:;;:OL.I!"4[:' F:!I",t[:' THE ,E:CITTC~H OF' THE Eh:CI:::I'v'FITICII",! (IN F.F:.';E;"F>. "!'HEF;:EE ]; S NO :!!.:,ET i'.i ! DTH f:'OR -f'RIEi".tE:HES. THE GRF:I',,,'EL. DEF'TH ]; '.!; 'f'HE H ;[ N :[ I'"II...IH [:'E;PTH OF' GRFI","EL E',F.";TI.'.IIZEN THE OLrl"FFII....!... I:::']; FIN[:, THE E:OTTOF1 OF 'TH[ii; E;h:E:FI'v'I:::I"I"i'ON (tN FEET>. I:::'EF;;:i',! ;I; T FIF'!:::'I.~ ~i; C:I::Ih,!T HFIS THE f;:% :'.:.'; f::' (31'.,l '_:~; ~ El Z [... [[ '1"¥ TO ~[ t'.lFr'~ f;;~l','l "I"H ;[ '.~i; DEF:'FIF..:TI','IIEI'-,IT 17:,l...If;~: ][ I'.,l(]i THE ]; Iqri':';'T'!::l!....IJ:::l'f' ]' '21'.,! ;I; I'..!L:.';PECT 1' '31'. ,1'_: :_'; FJF-" !:::lf",l"r' hI_[:ZL.._c: I::I["JI:::ICE'I",I'T' "[' "1 -I'H I 1~ F'f;;;Eff:'E";!~?.T"r' FtI",![:' t"! .. I'"I.~:~F'p r' F' Iq:IT:';::?.; I [:'EN(;;:IE:i~; THFIT THE; I'.IE%L 14 ;[ I.~!_ '.:];EI;;:","E. H ! N :[ HI..IH D :[ :i?f'l:::lhlCE E:E'i"I4EEI",t FI I,.!E;M... Ftht[> I::!l",l"r' ON-S :r. "I'E '.:SEI.,.ff::IEiE; ::l.!;~uFil FLEET FEll:;;: I::1 I::'RI',,,'F:rT'!E kiEL. f_ OF:: :1.5,9 TO ;?.El(~i t:::'EET FP. OH F:I [::'U[~I....iC HEL. L !:>E:I:::'EI'.,![:,INEi I...IPCIN 'TH!E T"r'I':'E OF PIJE:L:[C NELl_ .... H I F,! 1 I'"11...1!"1. D ]: S'rF!!'.,ICE FRO!"! !::1 F'I:;i: ][ ',,,'!::!T[?[ HEL.L. TO FI !::,1;i: :[ ?f:::!"I"E '.i:i;El.,.IEl:;i: L :[ NE :[ S ;;;!:5 F'EE.'T FI!'.,ID 'T'L'I F:t C:OHHUN!T"r' :;:7, EI.,.IEI:;i: I....Zt".!E ;(S '?5 FE:ET. ktE(L!.. I....CIC!iS FIR!E .[.;?.!i~).~:!1...I][[?[![[)!::11",1[)h!l...l?.i;T I!?,E F?._E:'T'LIf;::t'.,!.f:!Z:, TO THE: [>EF'F1Fi:'T'P'IENT OF '!"HE I,.IEI.J... CEff'!F:'I_ETIOi",I. OTHER REQU :1: RI!~:I'"IEI",IT:!i!; FIF:I"r' FIPF'L."r'. :SF'I'_:::C ]: F I E:FIT Z O!"4S F!i",ID CEII",I:~:iTf;~:UE:T F:I'v'F:I I L..I:::IE~LE; 'TO :[ N~;L.IRE PI:;tOF'EFi: ;[ NSTFIL. L. FIT .t.' ! CEI:;;:TIF:"r' THFIT J.: ~[ I::!1"I FFII"IlL..]:FIR !,.!!TH "I:'HE Fi:E(;:iU];REHENT::.4; I:::'Oi:;?. OI",I'":i!i; ]: TIE :.:.'.';EI,.!E!:;?.S I:::!t",![:' I.,IE:L.L:il!; RS :SE:T I:::CiRTH .E?T' ']"H[:.i: MI...IN :1.' C :[ PFIL .T. T"r' OF:' f:I!"4CHOI:;~:f:IGE. ;;?.: ;[ l'.l I I...I... Z I".!STFIL. L THE S'~"S'I"Ef"! I I",1 F:iCCOR[:'F!NC:E ['.11 TH THE 3: :[ I. JI",t[>E'F?.S]"Ri"4[:' THFI'f' 'T'HE OI",I~'"S].'TE :E;IEP.IEf;;: S'.r'i::.Vr'EH F'll::!"r' F?.E(;!LI]:I:;i:Ii~: E:HLI:::hq'.GE:HE!",!T IF' '1"HIE I:;:'.E:~2;ZDE;I",F::E: IS 1:;4Ei"IO[."E:L.E:[':' TEl ]:NC:LU[:'E ?'ICff;~'.E THFIN q. ,.. ,, .-~¢; ,/, ,..-,,. -. .., .i,: ,,.-- .... e [] ~OILS lOG MUNICIPALITY OF ANCHORAGE -i'~DBPARTMENTOF HEALTHA'ND ENVIRONM~N~A'LPROTEC~ION ~ PE~COCATiON 825 L. S,,eet, Anchorage; AIas". 99501; -~ 264-4720 : . .' SOILS LOG ~ PER~QL. ATIOB TEST ,:,, , ~ ~ ' .. '. ,. IF YES~ AT WHAT DEPTH? Reading Date ~Fim¢ , z Time Waler Drop .... · . . ~. ..... ~ -.,. COiwMENTS : ~ ......... ~ RETURh 10: D~vls:on of ~¢olog:cal aqd ~e 'ys;cal Sur,ey~ (08GS) STATE DF kLAS~A .3001 Porcupine Dr~ve /Tel~ ': Z77-6615) DE?ART~ENT 0F !~ATURAL RESOURCES oar WATER WELL RECORD Distance and DJrect;¢~ e~Igz~sect,ons~ ' SLreet Address and Area of Well Locat]on 2. '~ELL LOG Feet Sel~ Surface Gravel 0J ~9 ~e~ock ] 165 - 'Y~ a ~ e ~ -2U5 ----~ike, I 3. OWNER OF ~ruce Mattson Add ..... 617 Chetanika Loop ~aole River, Ak. 9957? WELL DEPTH: (completed) JJ8 [~lrr~ation F--~ ec~arge ~Cor,z~rc'al ~Test ';ell ~O?,er: .......... FINISH OP WELL: Tygegpen Hole O %,~e t er: Siot/~esh $;ze: Length: Set bet~en ~ and 9. STATIC '.ATER LEVEL: ~ ft. · ~jAbove ~Below land surface IO. PUMPING LEVEL below land surface ft. after hrs. pumping ft. after hrs. pumping 11. WELL NEAO COMPLETION: E]Pitless Adapter ] In Approved Pit ~nche$ above grade 12. GROUTING: Well Grouted: [] Yes ~aterlal: E~Neat Cer~_nt ~ Other: 13. PUMP: (if available) HP Length nE Drop Pipe ft. ca p~clty Type: E]Subn~erslble E~]Reciprocating [~ Jet [~Other: lq. REMARKS: Bail tested at 20 g.p.m. 15. WATER WELL CONTRACTOR'S CERTIFICATION: This well was drilled under my jurisdictlon and this report is true to the best of my knowledge and belief: Magnuson Drilling AA 5385 ~r~: P.O. BOX 504 Ea~le River, Ak. ~9~77 s~g.~d: ~ _~_,,<~.~. .....-- ...... o~te: Aug. l, 1981 Author ;ze~ Represent~ve '-~ / ~ c~ 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Tract lB, Itighland Terrace No. 5 Location (site address or directions) 10818 Steep&e Dr~ve Property owner Mailing address Lending agency Mailing address Agent Address 10818 Steeple Drive Day phone 694-2031 Eaqle River, AK 99577 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: Fi v~ (~) TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XXX If community wastewater system, provide written confirmation from State AD£C attesting to the legality and status of system. 724)25 (Rev. 1/91) Front MOA*21 STATEMENT OF INSPECTION BY ENGINEER As certified by my' seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/orwastewater 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 Anderson Engineering Phone 522-7773 Address P.O. Box 240773 AnchoraGe. AK 99524 '?~' ~!L-t (. Date Engineer's signature c ~ ~ r-~--¢~""~ 5/13/99 DHHS SIGNATURE J,'/"' Approved for ~-- ! ~" ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Addition~ Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-~725 (Rev. 1/91) Beck MOA ¢/21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Health Authority Approval Checklist Tract lB, Hiqhland T'errace #5 Pamel I.D.: If A, B, or C, attach ADEC letter. ADEC water system number ¥ Date completed 8 / 1 / 81 Cased to > 40 ' Y Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 Date of sample: 5 / 11 / 99 B. SEPTIC/HOLDING TANK DATA Date installed 8 / ;21 / 81 Foundation cleanout (WN) Date of Pumping 5 / 5 / 9 ~) C. ABSORPTION FIELD DATA Date installed 8/21/81 Length 8 0 ' .Width FROM WELL LOG 8/1/81 Casing height (above ground) Wires properly protected (Y/N) Y AT INSPECTION 4/.27/99 76' 42' 20 g.p.m. ' 8.3 Nitrate g.p.m. 1 . 61 mq/L Other bacteria Collected by: Tim Kimbrough Tank size 1,500 Number of Compartments 2 Cleanouts (Y/N).__ N Depression (Y/N) N High water alarm (Y/N) N Pumper JR' s Pumpin9 Soil rating (g.p.d./ft2orft2/bdrm) 226 SF 3 ' Gravel thickness below pipe 6 ' Y Effective absorption area 960 SF Date of adequacy test 4 / 27 / 99 Fluid depth in absorption field before test (in,); 0 Fluid depth 0 (ins) Minutes later: 24 Mrs. Peroxide treatment (past 12 months) (Y/N) N 72-026 (Rev. 3/96)* System type 6 ' Deep Trench Total depth 11 ' Depression over field (Y/N) N For 5 bedrooms Monitoring Tube present (y/N) Y Results (Pass/Fail) Pass Immediately after 747 gal. water added (in.): Absorption rate = >750 .g.p.d. If yes, give date N/A D. LIFT'STATION - None on Lof. Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line Size in gallons "Pump on" level at*. *Datum Liffstation "Pump off" level at* On adjacent lots > 100 ' On adjacent lots > 100 ' Public sewer manhole/cleanout SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation > 5 ' Property line > 5 ' Water main/service line > 10 ' _Sudace wateddrainage 2100 ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line > 10 ' Building foundation >10 ' Surface water > 100 ' Curtain drain None oJ.n ~,o~. ENGINEER'S CERTIFICATION I certify that I have determined in conformance with MOA HAA guidelines~n effect on this date. Engineer's Name F~J_chaei[ E- Andor.q~n; P ,E, Date 5/13/99 Absorption field. > 5 ' Wells on adjacent lots _ > 1 ri a ' Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots > 100 ' are HAA Fee $ [)ate of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment ReCeipt Number MAY-13-gg 13:58 FROM-CTE ENVIRONMENTAL Z'~ CT&E Environmental Set, ices Inc. T-~9 P.02/05 F-?07 CT&i~ Ref.# Client Name Anderson Eng~neenng Project, Narae//t N/A Client Sample ID TP lB Highland Ten'ace Matrix Drink/rig Water Ordered By PWSID 0 ~u]ap le Remarks: Client PO// Printed Date/Time 05/03/99 15.42 Collected Date/Time 04/27/99 12.20 Received Date/Time 04/27/99 t3.25 Technical Director: Stephen C. Ede Tote[ CoLiform NiCPaCe-N 10 OB/lO0 NL, NO tOLl 1.61 0.500 Limf~s Dare Date EPA 300.0 10 Received Time May,13, 12:59PM ~AY-13-gg 13:30 FROM-CTE ENVIRONMENTAL §815301 T-728 P.O1/01 F-T08 CT&E Environmental Service,,; Inc. Laboratorv Division r. ar_.~,~ar~Jf~'ar, sr~r,~ar-.ar,~r~'~'41''r~'~r~'ae''a~'~'~Ir~r'ar'~j~f~j' 200 w Pot[er Dr~ve )rinking Water Analysis Report for Total Coliform Bacteria t,.chora~, AK 99S~8-~ ~O~ Tel- (gO7) 562-2343 READ h¥STRUCTJON-V ON REVERSE SIDE BEFORE COLLECTING SAMPLE Fa^: (907) 561-5~0~ MUST BE COMPLETED BY ~"ATER SUPPLIER TO BE COMPLETED BY LABORATOP, Y Analys~s shows tins Water SAMPLE to be t3 PUBLICWATERsySTEM I.D-~ cii~P, IYAT£ WATER SYSTEM ~..$end Re~ults Q Senn lnvotce Day Year Time Collected SAMPLE DATE: Month SAMPLE TYPE; ~ Routine O Repeat Sample (for routine sample with lab ref. no. ) ~ Special Purpose Saust'actory D Sample over 30 hours old, resul*S may be unreliable Sample too long m ~ransit; samplr should nol Be ov~ 48 hoars old at exammanon to indma~ reliable restdm, Please senn new sample via sp~ci~ de~ m~,[. Analysis B~gan ~ ~ AnM~eal Me~hod; ~ Membr~e FilI~ fi MMO-~G * Nu~cafc~0 mi. Re~ulz* Analysl Treated Waler Untreated Water Collected ~m;n Fbkx Ju~l Foxed __ Time. Client notified of unsatisfactory results: PhOned SpoKe with DMe; __ Time: __ . BACTERIOLOGICAL WATER ANALYSIS RECORD MMO-MUG Re~ult: Total Colifmm Membrane Filter: Oiruc~ Count Verification: LTB Fecal Coliform Contlrmalion Final M~mbrane Filler Result~ E. Colt Colonies/t00 mi BCB __ COLIFIRM. ColiformYl00 mi Foxed .................... ~, .... ~,a.,,^ ~, ha,ha ,, ,,mAiq M~.R¥~AND MICtIIGAN. MISSOURI, NEW JERSEY. OHIO. WEST vIRGiNIA MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL Ph~TECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF iNSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name/~'~.'t.~_.r~,'.~_ ~:~----~.~., Telephone: Home ~eLY'-/-/'~'- "~ Business Applicant Address (c) Applicant is (check one): Lending Institution []; Owner/builder [~; Buyer []; Other [] (explain); (d)' Len ding I nstitution _L~_~ .~,? (e) Real Estate Company and Agent Telephone Address ..~hone (fO --.MeiiA~e HAA to the following address: TYPE OF RESIDENCE ¢ Single-Family ~ Multi-Family Number of Bedrooms. Other WATER SUPPLY Individual Well,l~' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL ~ Public [] Community [] Holding Tank [] Onsite Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025{11/84) 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 suppJy 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 _ ~ & ~ ~h~e~-h~ Telephone Address SRB l~6x Date E,%,ie ~i,'er, ~l,'tska 9~$77 DHEP APPROVAL Approved for '7~"'- bedrooms by Date Approved ~ Disapproved/J Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and [--nvironmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The MunicipaJity of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72*025 I11/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA/ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 aqgJ~l~.olP'Pd, tl¥ UF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MAR 0 ? 1986 264-4720 ~l ECl" I lie Well Classification _ --~.'~"~lk]~_ If A, B, C, D.E.C. Approved {Y/N) Well Log Preser~.b.c)- Date Completed ¢~:~' ~ - ~ 1 Yield Total Depth 4~6:~'~ Cased to. Static Water Level /'~ I Casing Height Above Ground Electrical Wiring in Conduit~.N~ Separation Distances from Well: Depth of Grouting "'--"' Pump Set At ~K Sanitary Seal On Casing Depression Around Wellhead~"~ To Septic/Holding Tank on Lot /O ~ i ¢' ; On Adjoining Lots To Nearest Edge of Absorption Field on I,.ot ,/00 '"~'-_ ,' On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole /d,J/~ To Nearest Sewer Service Line on Lot _ Water Sample Collected by ~ ~~--¢''~ (c~t~''~¢----'~-z-J,~('~ ; Date Water Sample Test Results _ Comments \// /'~'/ /(_)0 / ¢- /O,~ / ¢- B. SEPTIC/HOLDING 'rANK DATA Date Installed ¢""~.,/ Stand pipes~).N)~- Depression over Tank.¢~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well J f...Yo t ~ To Property Line '"~.---O l ~ To Water Maicu~ervice Line ~C)'¢ ~- Size /.%~¢ O No, of Compartments ~ Air-tight Caps ~ Foundation Cleanout (---Y'~ Date Last Pumped ..~z"../.._,~ ~, ; for Temporary Holding Tank Permit (Y/N) Course To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ¢ '~f~ ~ Width of Field ~0~1 Square Feet of Absorption Area ~:2' Depression over Field ~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Moil/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field (~(~)/ Depth of Fiel~ Gravel Bed Thickness Standpipes Present (~,~f~ Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots -~ ) c- To Cutbank (if present) /"///~ Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed $~B ~.~. Date ~-¢ ~ 7~ Company E~gle Receipt No. ~'] Date of Payment Amount: $ ~* ~')~ Page 2 of 2 72-026 (11/84) DA:FE RECEIVED INSPECTION APPOINTMENTS ~rlME TIME TIME DATE DATE DATE TNSPECTOR INSPECTOR I NSP ECTOB~, MUNICIPALITY OF ANCHORAG~ ~H~ALITY OF I, NCHO~AGI~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO~'~"~.pT' OF 825 L Street - Anchorage, Alaska 99501 ~RVIRONMENTAL P;:O [ECFION ENVlRONMENTALSANITATION DIVISION ~ ~ I~ Telephone 264-4720 O~/d¢ ~ ~ REQUEST FOR DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proceased. Please allow ten (10) days for processing, MAILING ADDBESS ~ 2 ' RES DENT (If different from abo~e) ' ~ PHONE 2 BUYER WA~L~NG ADDRESS ~. L~N~NQ ~N~T~TUT~ON MAILING ADDRESS /Og? 4. REALTOR/AGENT / ~ ~ ~ .HON~' MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION d/O 6. TYPE OF RESIDENCE NUMBER OF,BEDR~OO/MS . [~] One ~,. Four SINGLE FAMILY E~ Two E] Five ~ MULTIPLE FAMILY ~ Three D Six 7, WATER SUPPLY Other ~;;~. 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 dat~ give well depth (attach log if available.] 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** / fO~ / YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUFST BEFORE PROCESSING CAN BE INITIATED, THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS ,j~ [] ONE [] THREE [] FIVE [] OTHER SINGLE FAMILY [] MULTIPLE FAMILY [] TWO ~ FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY INDIVIDUAL DEPTH OF WELL [] COMMUNITY :)ATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED PERMIT NUMBER 3. SEWAGE DISPOSAL SYSTEM [] iN DIVI DUAL/ON -SITE DATE INSTALLED [ii PUBLIC UTILITY Connection Verified INSTALLER [~]Septic Tank or [~] Holding Tank Size: )_q~"-O~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line [ Nearest Lot Line WELLTO: /cOo I I Absorption Area to nearest Lot Line 5. COMMENTS ~-'~APP ROVE D FOR g/~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED //' '/} DATE BY f /-: ; '