HomeMy WebLinkAboutHENKINS BLK 3 LT 3
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP241135
Work Type: SepticTank Upgrade
Tax Code Number: 05129207000
Site Legal Address: HENKINS BLK 3 LT 3 G:0755
Site Mailing Address: 15731 OLD GLENN HWY, Eagle River
Owner: FINKLER GERALD & SHELLEY
Design Engineer: GARNESS ENGINEERING GROUP LTD
This permit is for the construction of:
Effective Date:
Expiration Date
Lot Size in Sq Ft:
Total Bedrooms:
I)c�partrrrc:��rr
6/24/2024
6/24/2025
20038
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: t � s Date:
Issued By: Date: � 2_ 712op
3
ON -SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051-292-07
Property owner(s) GERALD& SHELLEY FINKLER - C/O ARM SEPTIC SERVICES Day phone 907-688-9433
Mailing address 17933 OLD GLENN HIGHWAY, CHUGIAK, AK 99567
Site address 15731 OLD GLENN HIGHWAY, EAGLE RIVER, AK 99577
Legal description (Sub'd., Block & Lot) HENKINS; BLOCK 3, LOTS 3 & 4
Legal description (Township, Range & Section)
Lot Size
Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field
Fj
Initial 0
Single Family (SF) FX�
(w/wo ADU)
Septic Tank
0
Upgrade N
Duplex (D) D
Holding Tank
El
Renewal ❑
Multiple Dwellings 0
Privy
El
(SF and/or D)
Private Well
0
Water Storage
0
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
Permit No. 0,5 P 2- J 1135-
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GMevelopment S ervices\Bu il ding Safety\On Site Water and Wastewater\ForTns\Client Forms\Permit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241135, Curtis Townsend, 06/24/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241135, Curtis Townsend, 06/24/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241135, Curtis Townsend, 06/24/24
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Fb 24-1, pg 38-39
Fb 07-1 ! pg 11 -12 BE
COMMISSIONER'S DEED OF VACATION
(Corrected 12/21/77)
The grantor, State of Alaska acting by and through its
Department of Highways acting under the authority of the Alaska N
Statutes, Section 19.05.070, for and in consideration of the sum Go
of one and no/100 dollars ($1.00), and other valuable consider-
ations the receipt of which is hereby acknowledged, conveys,
quitclaims and otherwise vacates unto those persons or their
heirs, successors or assigns in whoa the following described
Property was vested at the time of acquisition by the State of
Alaska or its predecessors in interest, all interest of whatsoever
nature which it has, in the following described real property s
situated in the State of Alaska, to wit:
The northwesterly 50 feet and the southeasterly 50 feet
of the 300 foot wide Glenn Highway P.L.O. right-of-way, co
located within Section 30, T. 15 N., R. 1. W., Seward tn
Meridian, Third Judicial District, State of Alaska, as
delineated on a sketch map which is attached hereto, and by
this reference made a part hereof.
This conveyance is made in accordance with AS 19.05.070.
Dated this nG ' day of-..�Sa_.,_ 1977.
This document is being re -recorded in order to correct the
legal description of the lands involved from T.14 N., to T.15 N.
RECOMMENDED FOR SIGNATURE STATE OF ALASKA
DEPARTMENT OF HIGHWAYS
.r By:
ineor antra v s on Eng �•
Commissioner o Hghwaysr.
STATE ACKNOWLEDGEMENT
STATE OF ALASKA )
-
FIRST 3UDICIAL DISTRICT) '
ON THIS ZC& day of U�� , 19 7�, before me,
the undersigneT, a Notary PubZ% in an or a $aid State, per-
sonally appeared ae,. a-2 , Commissioner
Of Highways for the State of'7 las a, tanown to me to be the iden-
tical individual who executed the foregoing instrument and he
acknowledged to me that he executed the same for and on behalf of
the State of Alaska, Department of Highways, with full authority
so to do and for the uses and purposes therein mentioned.
IN WITNESS WHEREOF, I have hereunto a nd affixed
sY official seal the day and year above w,td'y
!'`• }
My Commission Expires:
N ,
#AV co"AaSSION EXPIRES • ;�► t CO
.TUNE 7, 1979 VaaBt�a r� 8-0 6-1
ADDRESS OF GRANTEE
William i Marianna Koehler, ET AL
P.O. Box 279 partment of Twncportatom
Chugiak, Alaska 99567 br niblic F:t6hdes
Cow. Ae;. P.i\V hft- ion
Knich UAO
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 ~ j P E ~ NEW
Absorption are~ ~ Dwelling . / ~ PER~
~ M~nufacturer ~ree/ ~~ / .o. of~o~portments ~
~ Liq.~a>~ons IF HOMEMADE: Insidelength ' Uquiddepth
~O' D ISTANCETO: Well i--t~/ Dwelling P ERMITNO.
~ ~ ~ Manufacturer Material ~ Liquid capacity in gallons
~ DISTANCE TO: -- n?i~ --inches
~ No. of lines/ Length ~h ,i~ ~ Totagn~i n~~ Tre . Distance b
f~ ~--~~' ~r M.er,a/ be,,~th tile. i r~ ~ Total eff~iv~rption area
~ inches
Length v ~ Width ~ Depth / PERMIT NO,
/
/
~ ~ Type of crib Crib diame~r~ /~ Crib depth Total effective absorption area
~ DISTANCE TO: Well ff Building foundation Nearest lot line
~ Class Depth Driller Distance to lot line PERMIT NO.
m Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO;
OTHER O
SOILTESTRATING : :~ i~~
INSTALLE~ /
/~ ~,..:.,,W%.,-~:::~'
APPROVED~ /~/ ' -':-,-~¢-~' ' DATE LE6AL
F'ERH. I T NO.
F!F'F'L i Cf:INT
LOCRT I ON
LEGFtL
1.,.! ILL. I FIM k!FITK I hiE;
HENKI NE; '...5,.'"[:' CHUGI!aK
LO']" 3: 8LK ]: HENKINS
BOX 2:!2 ER
LOT SIZE
69q.-979E~
2EE~EIE~ SQURRE FEET
'T:T'F'E Cfi:' SOIL FIE:SOF.:PT!ON :~,E'STEM IS: TRENCH
MRX~MUM NIjMSER OF E:EE:,ROO!"19 = /~ ~ E;OZ[.. RFr'FZNG ,::SQ FT?E:R)=
THE RE '2 .. ! REE:, SIZE OF THE :SO:IL F]E:SORP'!"ION 2;?:STEM If5:
THE LENGTH DIMENSION IS THE LENGTH (:[iq FEET) OF TNE TRENCH OR DRRiNFIELD.
TE!E DEF']'N OF' FI TF:ENCH OR PIT IS THE DIS'TFINC:EE DETNEEI",! THE.' SUF.':FFICE OF THE
GROUN[:' RNE:, '!"HE BOTTOH OF' TH.E' ENCFIVRTZON '.'.'IN FEE]").
THERE tS NO E;ET !.,.IIDTH FOR TF<ENCNES.
THE: C'~RFiVE.'L E:,E'PTH :[% THE .r'IiN:[MUH. DEPTH OF GF.:R',/EL BETHEEN TEIE OUTFRLL. PZF'E
FIN[:, 'THE E:OTTC'M C,'F THEE EXC:FI'¢RT:[EtN "IN FEET). /*~2~2~2 ~Z¢/]~¢~
PERMIT RF'F'LiCRN]" FIRS THE RESPONSIE:ILi]"¥ 'TO INFORM THIS DEF'RRTME:NT DURING ]"HE
INSTRLL.RTION IN%PEC:T!ONS OF RN'¢ HELL'-E; RD..!RCEI",FF "['0 "FEt!S PROPERT~¢ RN[:' ']".FIE:
t",!UME:ER OF F.':E'.E;IDENCES ]'.,""IR'[' TNE HELL NIL. L SERVE.
BRCKF!!.J_ING OF RN"? S?STEM HITHOUT FINf~.L INSPECTION .~ND RPPRO",,'RL. E?'r' THIS
DEPRRTMENT HiLL BE '::;UBJECT "FO PROSECLIT!ON.
MINE[MUM [:'ISTRNC:E 8ETHEEN R WELL RND RN? ON-SITE SEHRGE DI'=;POSF~L. S"?STEM IS
±C~E~ FEET FOR R PRIVRTE NELL OR 15~.~ TO 2¢-'}E~ FEET FROM R PUBLIC NELL DEPENDING
UPON THE T".,"PE OF PUBLIC !4EL. L.
M.T. NIMLIH DISTRNC:E FF.:OH R F'RI"/RTE HELL TO FI PRI"/RTE SEHER LiNE IS 25 F'EET RE,iD
TO ..¢~ COMMUNITY SEHER LINE IS 75 FEET.
HEL. L LOGS RRE RE:QUIRE[:' FIND MUST BE RETURNED 'TO 'THE DEF'F~RTMENT HITH:[N
OF THE .WELL COMPLE'FION.
OTHER REQUIREMENTS H.R'¢ RF'F'L?. SPECIFICRTIONS .~ND CONSTRUCTION DIFtGRRMS .F~RE
RVRILRBLE TO INSLIRE F'ROPER !NSTP, L.LRTION.
! CERTIF"/ THRT
±: I RM FRMIL:[FIF.: HiTH 'THE REQUIREMENT:'E; FOR ON-Si"f'E :gEHER":; RND HEI..LS RS SET
FORTH E',"¢ 'THE MUN!C!PRL. IT'-/ OF' FINCEIORFIGE.
2: I HILL !NSTRLL TFfE :?-?STEM IN ,'.':tCCORE:,RNCE HITH THE CODES.
]:: z UN[:,ERSTRND THRT THE ON-SITE SEHER $','¢STEM MR'¢ REg!UIRE ENLRRGEMENT IF' TNE
RESIDENCE IS REh'!ODELEE:, "ro iNCLUDE MORE THFIN 4 BEDROOMS.
S i GI'.!E[): ~,z"_/'.~t'~~...._.L_.z?.../~,"-~Z"~C ....................................
FIPPL. ): CRNT H:[LLIRH HRTKINS
ISSUE[:, ~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
1
2~
3
4
5
6
7
8
~0
12
14
15
16
17
18
19
2O
SLOPE
COMMENTS
t
ENCOUNTERED? .
IF YES, AT WHAT
DEPTH?
/%/O
//~ SOILS LOG
[] PERCOLATION
TEST
DATE PERFORMED/6
SITE PLAN
pERFORMED BY:
~r)bert A.
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
/~FF~AND
(minutes/inch)
~ FT
leal Surveys (DGGS)
~ v slo;. of Geolog c~l and Geoph~i 277-6615)
InOcOLPraO~,~p~Lne Dr'rs [Tel epi y A~%s ka ~501 ~.
RECORD
()tilling Company Name --
STATE OF ALASK~
DEPAR'(-MENT OF NATU~J~L RESOURCES
U.S.G.S. Local No.
Drilling Permlt No.
A.D.L. No.
LOCATION OF WELL J Please complete either la, lU, ur ~
la. Rorough J Subdivisi~l Lot Rlock lb. Fraction Section No. Township Range ~er~dlan
lc. Distance and Direction From Road Intersectlons ' 3. OWNER OF WELL:
Address:
Stree~ Address ar,~ Area of Well Location
'~' Feet BelOw 4. WELL OEPTH: (completed) S~rface Elevation gate of
Completion
Mater~ial Type Top Bottom
~" 6. USE: ~Do~stlC ~liC Supply ~lndustry
~ , ~Test Well ~OLher:"
. 7. CASING: ~ Thr~ded ~Weided
lbs/ft.
' I~ in. to ft. Depth
Fittings:
~ 9. STATIC WATER LEVEL: ( ft.
~A~ve ~Below )and surface
Type of Heasur~nt:
~ 10. PUHPING LEVEL bel~ land surface
~ ft. after hrs. pumping
, ft* after hrs. pumplng g.p.m.
v ) 11. WELL H~O COMPLETION: ~ In Approved Pit
. . inches
~.~. ~.,, ~P t ess AdRpter aboye grade '
.~ Material: ~Neat Ce~nt ~Other:
~' 13. PUHP: (If available) HP
~ Length of Drop Pipe ft. ca~clty ~ . g.p.m
Type: ~Subn~rsible ~Reclprocating
MUNIC
' )F HEAI~TH' &::HUMANSERVICES!
Ei~Vi f~ n m ~iYtal! ~'e ~)ic~i~
3ATE
(site 'adiJi;ess Or direCtion~)
'" i~.: .:'.,,~:,,_'ii.
~Y.OWne[
:-;Mailing address Z.z>~;¢~-~ ~'¢.¢~"' ~.~ .
. .ending agency Day phone
~-"Mailing address:', ,.
..: .. Agent ','~-~(,'w' Day phone ,,
Address · ' :'..-. ' '. ' -..; ' ';-: '
Unless otherwise requested, HAA Will beheld for pickup;
;':' '-.: ii:-~' '" , ' ' .......... :.;~ :N '::'
2/;' NUMBEROF BEDROOMS:- ' -;-~. .
3;. TYPE OF WATER SUPPLY: ' .'
- ~n§
Individual .well
Oommunity well ' '.:
Public:wate~ :~:
' wi'i~te~'con~firma'tion' from
~" ?'"" NOTE: ' If community Wastewater system, provide written confirmation from state ADEc':
-;'. : ~ . a~esting to the legali~ and statbs Of'sYStem~'
(R~.1/91) Front MOA~I
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Municipality of Anchorage ,/~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /-'~1- ~'/¢'~' ¢~-/~,.~ /~¢J~',~-¢ ~ Parcel I.D.
A. Well Data
Well type
Log present (Y/N)
TOtal depth
Sanitary seal (Y/N)
Date of test
If A, B, or C, attach ADEC letter. ADEC water system number
Y
FROM WELL LOG
Static water level
Well flow
Pump level1
Date completed ////~-/,~.;:~- Driller .~¢5 ~)¢,,.~¢~J~
/
Cased to~,;;~.; ,w~ Casing height
Wires properly protected (Y/N)
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
ATINSPECTION
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank . ,~'~
g.p.m.~
WATER SAMPLERESULTS'
o ~/,¢/,Z'~'
Coliform O ;¢/~/¢¢' Nitrate o¢/o ~/~/'¢,,/ Other bacteria
~/¢ff 3/3//¢ ¢ Collected by:
Date of sample: ~/~/¢y ~.~ ~¢~ ~¢ ~o ~ ~,,,~
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping ~ Z 5'/
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /¢¢~ On adjacent lots
To property line ~,C> Absorption field
Surface water/drainage /z~:~
Tank size l c-¢_.~c~ Compartments 2_..
Foundation cleanout (Y/N) ~ Depression (Y/N) /"/
,KJ//~- Alarm tested (Y/N)
/¢¢~ Pumper
Foundation ~ '
Water main/service line /~' =~-
CONTINUED ON BACK PAGE
72-026 (3/93)* Front · ~ .: : . :
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
.Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed ~///~ -..~
Length ~.6/~ ~ Width
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/Ft2) ¢~.~'~/~,~
..¢, ~,.~¢- Gravel thickness
Cleanout present (Y/N) ~¢
Results (pass/fail) ¢i74~'---~
System type
Total depth ¢
Depression over field (Y/N)
for ~ Bedrooms
Aftertest ~'~ ~.,,.~-~c~,-~ ~
t// If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots / ~'/- Property line
,/¢ ¢ To existing or abandoned system on lot _
Cutbank ~'c~ .~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
David R. Dayton P.E.
20210 Donalar St.
Chug|ak, Alaska 99567
Signature
Engineer's Name
Date
HAAFee$ r~cOO
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
D. R. DAYTON, P.E., Ri.S.
~ Chu§iak~ Alaska 99567
20210 Donalar -
(907) ~
696-2417
April 4, 1994
Legal Description: Lots 3 & 4, Blk 3, Henkins Subd.
Date of Test: March 23, 1994
Well Depth: 260 ft.
Static Water Level: 33 ft.
Requirements: 3 BR _7~ 450 gallons per day, 0.31 gallons per minute
Test:
A Flow Tech pu~p protector was temporarily installed on the system.
The well was then pumped down until the Flo~ Tech shut off the pump.
The pump was restarted 60 minutes later and the ~ run~ until the Flow Tech
agiin shut the pump off.
The volume pumped from the 60 minute recovery time was measured.
The process was repeated for 4 cycles.
Results:
The well produced an average of 32.6 gallons per hour or 0.54 gallons
per minute.
The well is currently producing adequately for a 3 BR home.
D. R. DAYTON, P.E., R.L,S.
~ Chugiak, Alaska 99567
April 4, 1994 .- ~
(907) ~
696-2417
Legal Description: Lots 3 & 4,
Date of Test: March 7, 1994
Septic Tank: 1000 gallon, 2 ca
Absorption System: 26' long x
Soils Rating: 85 sq. ft. per b
ADEQUACY TES~
Blk 3, Henkins Subdivision
k3rtment, steel tank (DHHS Records)
~0" wide x 5' effective depth trench (DHHSRecords)
~Lroom (DHHS Records)
Requirements: 3 BR - 450 gallons per day
Test:
Water was pumped i~to the absorption ~rench while measuring volume,
time and water level rise.
Results:
The trench had no standing water before the test. After adding 465
gallons to the trench the water level had not risen enough to measure.
The absorption trench is currently functioning adequately for a 3 BR home.
' ' · ' ~,,~,~.1~ ~ '~ ~ . ' I Anchorage Recording Distrfct~ Atask~ a~ .'
' ' '¢,%% $hano'~ H~fi': ~2 ' ' overlap o'r encF;a~ on the pro~rty
. 4~E~_*% [S6914 ' .¢~ Lying adjacen~ thereto, that no .. .
IHFO~TI~ HEREON I$ FOR THE USE.OF LE~DIHG ' . , eas~ents on said property except as
THE SpECiFICALLY TO SH~ ~Y COHFL~CIS EASE iENTS OF RECORD, OTHER [ J~icat~ hereo~.4 Dated et A~horage,
~OlI ~AL STRUCTURES ~ ~ENCELIHES ' SH~ HERE~ ' : · :',' :-' ' I HOLT AND ASSOCIATES LAND SURVEY~S ,'
SINCE )908
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~~z;7~z~£~/~7~
LABORATORY ANALYSIS REPORT
CT&E Ref.# 94.1254-1
Client Sample ID L3 B3 HENKINS SUB.
Matrix WATER
ClientName DAVID DAYTON, P.E. WORK Order 76891
Ordered By DAVID DAYTON Pr'mtedDate 03/28/94 @ 14:05 hrs.
Project Name Collected Date 03/23/94 ~ 14:00 hrs.
Project# Received Date 03/24/94 ~ 11:20 hrs.
PWSID UA
Technical Director STEPHEN C. EDE
ReleasedBy: ~ ~. ~
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: D.R.D.
Parameter
QC Allowable Ext. Anal
Results Qual Units Method Limits Date Date Init
Nitrate-N 0.10 U mg/L EPA 353.2/300.0 10 03/25/94 LLH
* See Special Instructions Ab ore UA=Unavailable
** See Sample Remarks Ab ore NA = Not Analyzed
;~; U= Undetected, Reportedvalue is thepractical quantification limit. LT= Less Than
~ D = Secondary dilution. GT= OceaterThan
5633 B Street, Anchorage, AK 99518-1600 --Tel: (907) 562-2343'Fax: (907) 561-5301
I=~i~/l~",td~a~tdTAI ~:APII Itl~:C: ltd Al AC:k~A ('hi n~bnn FI nRInA II I IN{31.~ MARYLAND. NEW JERSEY. OHIO. UTAH. WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE'
DEPARTMENT OF HEALTH & HUMAN SERVICES
' Division of Environmental Services
- ," On.Site Services.Section
P.O. Box 196650 Anchorage,'Alaska" 99519-6650
· . CERTIFICATE OF HEALTH AUTHORITY
' APPROVAL FORA SINGLE FAMILyDWELLING:
Parcel I.D. # ~)~ ~' ~_,~o~.=~_
1. GENERAL INFORMATION .~ ~,~,~.L.~-'4:
Complete legal description LoZ
Location (site address or directions) 15737 O£d
Pro perty owner
William & Ph~llis Watkins
Mailing address
Lending agency S~attle Mortgage Corporation
..... ATTN: Dic~ Mant~
Mailing address 560 Ea~ ~4~ 4.¢v.v.e ~.~¢ ~n4
770212 Eagle River. Alaska 99577
Day phone
Day phone
Day phone 696-2244
Agent Don McK&nzi&
A~.99503
694-9035
Adaress P.O.Bo× 772722 Eagle River, Ak. 99577-2722
- ' Unless otherwise requested, HAA will be held for pickup. . ~. ..... .~- ~.':~. · ~i - -
2. NUMBER OF BEDROOMS: $ "' ': '"
3. TYPE OF WATER SUPPLY: "'~
Pub ic 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:
X~c .
nd vidual on-site
Holding tank
Community on-site
Pub ic sewer
NOTE: if community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
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Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Lega~ Description: J~c~l' '~ ~..V.--~ ~-/~5 ~/r) Parcel I.D.
A. WELL DATA
Well type ~P,/~'~'F:,---
Log present J~N) X~
Total depth '~.o~ ~
Sanitary seal ~N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~, 7---~1 f~t Driller
Casedto ~ ~ ~,~, Casing height
~ Wires properly protected ~N) ~
Date of test ~ ~ '*~ ~ ~ q ~
Static water level O~
Well flow ~, O g.p.m. ~ '~
Pump level 0 ~ ~ ~ ~ '
SEPARATION DISTANCES FROMWELLTO: ¢LoFE ~ ~5~. ~/~ ~5 ~du~
; On adjacent lots '~
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed ct -'
Cleanouts (~N)
High water alarm (Y/~g~
Date of pumping
Nitrate O,/---~-~" '~'~.
Collected by:
Other bacteria
S & S ENGINEERING
17034 Eagle River L.eOp Roa~ ~o. ~- '
Eagle River, Alaska 99577
Tank size \ OfF, (:~ Compartments ~-
Foundation cleanout~YN) y Depression (Y/~
Alarm tested ~:. r ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot lc>c> ~'~ On adjacent lots
To property line I ~ Absorption field
Surface water/drainage ~ ~ ~-
Foundation
Water main/service line
72-0~6 (Rev. 3/91)Front MOA21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
Manufacturer
"Pump on" level at
High water alarm level ~
Meets MOA electrical codes ~
VV~II on lot On adjacent lots
Manhole/Access (Y/N)
_~t
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed :~%'~
Length '~. 6¢' Width
Total absorptidn.area
Depression over field (Y~
Results~fail)
Peroxide treatment (past 12 months) (¥~
Soil rating ~¢ ¢~
Gravel thickness
Cleanouts present.N)
Date of adequacy test
for
,,J~.¢~ /4~/¢¢'~¥ If yes, give date
System type 'T~ic.c_.-,-l~d
Total depth ~, ¢' ¢ ~'
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /o~ ~¢-
To building foundation
On adjacent lots '~(~ ~'~-
Surface water \ O~
Curtain drain ~ I~-
E, ENGINEER'S CERTIFICATION
On adjacent lots / co ' ~- Property line
To existing or abandoned system on lot
Cutbank '~o ~'~ Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect,~q¢.J,h,.e date of this inspection.
S & S ENGINEERING ~' '-a, ,,.':, '-.:..- ' '¥,' %
Sig natu re ---17034 -"'~.¢, RI,vet L~.~p Rea,~ No. 2~ ¢
.... Eagle River, Alaska 99577 ~
~nglneer s ~ame ~
Date ~ ¢~ /
HAA Fee $ /
Date of Payment '
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
APPLI{ ' NT FILLS OUT UPPER HAV- .ONLY
Phone
Property Owner~,--2/~*; // (/~'(~ ¢"-'¢ /~"'~
Mailing Addre~ ~ ~1'~ ~ ~, /t) 2.'~ ~ v~ ~ Zip Code
Buyer ' ~'' ~ ~ ~ ~ -' " / ' ''
Address Zip Code
Phone
Lending Institution
Ad~re~s ,~;~.,.., ~ Z~p Code
Realty Co. & A~nt Phone
Address Zip Code
Type of Resi~nce ' .... 7 ' ~
~ Single Family
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
~ Individual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility
Sewer Disposal
Individual Year Individual Installed:
~ Public Utility When Connected to Pubhc Uhhty:
. ~ 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 Inspector Inspector
( ~) APPROVED SEDROOMS °CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
~"* ~--~/f Well to Tank Septic Tank Size /~'~0