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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 a- 0 wd°�«z .:\. \\�i tV60 3 58 Ootjp,v 63 0.. 00 0,14, LOT 13 M= 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 sluetuLuoo le~O!)!ppv :suop,~' nd!ls 8U.MOIIOJ. eql ,ql~M 'SWOOJpeq 'SU~OOJpeq .g 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 ;..-;,<; _ ....... szuewwoo leUO!~!PP¥ :suop, elndp, s 6u!~OllOJ eq~, q~!M 'suJoo~peq Joj le^oJdde leUO!~!puoo euoqd 'SUJOO.Jpecl ~,' ~OJ peAo,Jddv ~ gl:lnlYN~lS SHHa '9 eJn~euS!s s2eeu!Du=l sseJppv w J!..4 jo eweN {)NllgiiINIONg S ~' ~ · uop, oedsu! s!q), jo e~ep eq~, uo loeb@ u! suop, elnSeJ pue 'seoueu!pJo 'sepoo e~e),S pue led!o!UnlAI lie q~!M eoue!ldLUoo u! si Lue~sXS lesods!p jm, eMe~seM Jo/pue/~lddns Jm, eM m,!s-uo eq~ 'uoRoedsu! pue u~)Re6Rse^u! XLU LUO~J pue Sel!J eDe~oqouv bo/q!led!o!unlR ~uoJj peu!e~qo uo!~ew~o,tu! eq~, uo peseq ~,eq~ XjIJe^ JeqMnj I 'u!eJeq pe)eo!pu! eJn~om~s jo edX~ pue suuooJpeq jo ~eqLunu eq~ JoJ e~,enbepe pue leUOp, ounj 'ejes s! uue~sXs lesods!p Je~eMm, seM Jo/pue Xlddns ~e~eM @~!s-uo eq~, ~,eq), SMOqS uop, eO!ldde le^o~ddv X~poq~n¥ q~,leeH s!ql jo uo!~eBp, se^u! Xw ~eq~ Xjpe^ I 'Moleq uMoqs e~ep uo!~ep!le^ eq~ jo se pue o~eJeq pex!jJe leds ~Lu ~q pe!J!peo sv ., M:gqNIDN3 A8 NOI.LO:IdSNI JO J. NglN3.LV.LS  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