HomeMy WebLinkAboutHERITAGE HEIGHTS #1 LT 25A
NAME
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
PHONE
3 3 3-5/~b E]UP~R'~DE
MAI LING ADDRESS
LEGAL DESCRIPTION , . / - ~ [J/ ~ /) .
Well ~ ~ Absorption area t Dwel lng ~ .
. ~,S~ANC~ TO: I~1 ~ ~~ ~ ?~
J ~ ~ J ~0..~ ....... ,~ /- , I ~erial / ~ . No. of compartments
~ Liq. cap~ci~ in gallons ~ ,,~,,~,,~ ~ Inside length Width ~ L~quld depth ~
5 ~ Jwel~ ' ~ J Dwelling PERMITNO~
~ = = ~ O,STANC~ TO~ ~ ~ ~ ~ ~_ . . .~
O ~ ~ ~ tur~/ ~Material ~u~pac~ty m gallons
· _ ~ Manuf~
~ /We~ j0~'~ ~o~a~i~n ~ ~ .~1JNearestlotlin~e~ / PERMIT~.~ /
~= J DISTANCE TO: ~~ ~ ~U I ~ //~
~g No o ines ngth o~each I' ~ota]le~gth of lines Trench w~dth ~ Distancebe en Jines
~ ~ ~ ~ To~ of tile to finish grade -- i Material beneath tile .. Total effective abs~p~on area
~ ~ " ~ ~ O inches O ~ (~
~ Length Width Depth PERMIT NO.
~ ITypeofcrib/~ame~r Crib~ [Totaleffecti~~ ' ~ ~
~ I / Well ( / B~dingf~tion~ I~lotJine
~ I ~ANCE TO: ~ - ~
~ ~.~~ ss ' Depth Drill~Driller I ~mn~lDistance to lot line I PERMIT NO.
~ ~- ' ~ g 8uildin~ foundation Se~r line I Septic tank I Absor0tion area(s}
> I DISTANCE TO: ~ I
OTHER
PiPE MATERIALS
SOl L TEST R.~TING
1oo
DATE LEGAL
Ot-~--S I TE
PERMIT NO. ( 790~726 )
APPLICANT
LOCATION
LEGAL
I C I ~-~L I TN) ~Z~F 8~-~L-:-H~Z~RAGE
DEPFtRTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 ~L~ STREET~ 8NCHORAGE~ AK. 9950i
264-4~20
~E~E~ PER~ · T
EDWIN POWELSON
OFF ABBOTT RD
L25 HERITAGE HEIGHTS
4~25 E. 9TH AVE
LOT SIZE
50000 SQLARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS
SOIL RATING (SQ FT/BR)= 100
THE REQUIRED SIZE OF THE SOIL ABSORPTION -z~-~,, IS:
[:,E PT: :~ ~l~' LEt-.~-JTH= ----<J- ~iR R'.." E L DEF'TH~= 5
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF 8 TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE E~CAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
REL~--:LI I RE[:, SEPT I C TRI'-~K S I ZE= i000 GFILL~31%~S
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NU~AER OF RESIDENCES THAT THE WELL WILL SERVE.
TWO <P> I ~-~SF"E~;TI~ZIt-~S R~E RE~zL:IRE[:,
BACKFILLING OF 8NY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A NELL AND ANY ON-SITE SEWfGE DISPOSAL S~STEM IS
~00 FEET FOR 8 PRIVATE WELL~ OR
i50 TO 200 FEET FROM A PUBLIC NELL DEPENDING UPON THE TYPE OF PUBLIC WELL.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS 8RE
AVAILABLE TO INSURE PROPER INSTALLATION.
PEE:NIT EXPIRES DEC:E£'IBER 31, 1979
I CERTIFV THAT
l: I 8M F8MILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
APPLICANT EDWIN POWELSON
_ 2
~/ CONSTRUCTION TEST L~B
"One Test is worth a Thausand Opinions"
'2204 Cleveland Anchorage, Alaska 99503 277-0231
Perfo~ned for Western Enterprises
Legal Description: Lot 25 .'Block
This Fo~n reports: SOILS TEST Yes
Date Perforqned 6/20/79
Subdivision Heritaqe Heiqhts
PERCOLATION TEST
Depth
Feet
Soil Characteristics
6" Peat
T. 5' Reddish Silt
~.5' Brown Gravglly Silt
14'
Brown Clean Sandy Gravel
(GW - GP)
Bro%~ Silty Sandy Gravel
Bottom of Test Hole
Was ~round Water Encountered No
If YES, What depth?
Reading Date I Gross T~ne I Net TL~e Depth to H20 Net Drainage
Percolation Rate Minute
Proposed Installation: SEEPAGE PIT DRAIN FIELD
Depth of Inlet Depth to Bottom of Pit or Trench
CO~C4ENTS: ~-00-Square Foot drainage area required per bedroom ~rom
minus 3.5' to 14'.
Test Performed by
Data Certified By:Construction Test Lab
Date : 6/21/79
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
~) { ~'~ ---~ ~ {- '¢' ~'" HAA#
1. GE"ER.AL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Day phone ~'~ ~ 2~2,¢~L
Lending agency
Day phone
Mailing address
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
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:
If community wastewater system, provide written confirmation from"State ADEC
~ttesting to the legality and status of system.
72-025 (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/orwastewaterdisposalsystem is safe, functionaland adequate for the number of bedrooms
and type of structure indicated herein, lfurtherverifythatbasedontheinformation obtained from
the rvlunicipality 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 ~'~h~,.~, ~ ??-- D~L3 ~'?~ Phone
E ngineer'ssignature . ~_~.~--~. ~/~-~/~' Date ~c~//~_~
DHHS SIGNATURE
Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional 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 er,rors or omissions in the professional engineer's work.
72~)25 (Rev. 1/91) Bsck MOA ~21
Municipality ct Anchorage
" Department of Health & Human Services.
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /of- ~'5~'' //-/~D~';~,~~ /]~/&'//'/~' Parcel I.D. ~ / 5/-
A. WELL DATA
Well type
If A, B, or C, attach ADEC letter.
Log present (Y/N) ~Y
Total depth
Sanitary seal (Y/N)
ADEC water system number
Date completed ~//~/~-~' Driller 5y,~_~'~
Casedto''~&~/ ? Casing height ~
Wires properly protected (Y/N) Y'
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
~=,~O g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot //
Public sewer main
Public sewer service line
WATER SAMPLE RESULTS:
Coliform F--'P Nitrate
Date of sample: -~/£/,/~ ~'~
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed C//~../?~
Cleanouts (Y/N) ~
High water alarm (Y/N)
Date of pumping
Other bacteria
Tank size I o ~c) Compartments ~'~
Foundation cleanout (Y/N) Y ~ Depression (Y/N)
~ ~'-~ Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /~0 < On adjacent lots /~'~
To property line ~ 5 *t Absorption field
Surface water/drainage '~
72-026 (Rev, 3/91) Front MOA 21
Foundation ~ ~ ~'~
Water main/service Ii ne .5-0 ~
CONTINUED ON BACK PAGE
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date insta,ed
Length -~ .Width ~ /
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
On adjacent lots
Surface water
Soil rating /D~;~ System type ~;~¢~/4//'
Gravel thickness Total depth /;¢~ /
Cleanouts present (Y/N) )/ -
Date of adequacy test ¢.~./~./'/~ ~ ~'~
for '-~ ~ bedrooms
/'~ - If yes, give date
Property line
To existing or abandoned system on lot
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /'/-~ On adjacent lots
To building foundation ~ ~
On adjacent lots /~ o~.~ Cutbank /L/o~¢ Water main/service line
Surface water / ~¢ ~ Briveway, parking/vehicle storage area..~
Curtain drain ~ ~¢ '
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.
Signature
Engineer's Name
Date
HAA Fee $ / 70~-~
Date of Payment
Receipt Number
72-028 (Rev, 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
D. R. DAYTON, P.E., R.L,S.
HC 78 Box 1026 Chugiak, Alaska 99567
February 22, 1992
WELL FLOW TEST
(907) ~~
696-2417
Legal Description: Lot 25, Heritage Heights Subd.
Date of Test: February 21, 1992
Depth of Well: 86' ( 6' of casing has been added to the top of the well. )
Static Water Level: 63.7' below top of casing
Standards: The Municipality of Anchorage requires a flow of 150 gallons
per day per bedroom, or 450 gallons per day for a 3 bedroom
house.
Test:
The well was pumped at increasing rates varying from 3.8 to 7.0
gallons per minute for 1 hour 50 minutes. The average rate was
6.1 gallons per minute.
Results:
The well produced 675 gallons in 110 minutes. The drawdown of
1.5 feet was fully recovered in less than 5 minutes.
Conclusion:
The well is adequate to meet the Municipality of Anchorage Standards
for a 3 bedroom house.
D. R. DAYTON, P.E., R.L.S.
HC 78 Box 1026 Chugiak, Alaska 99567
February 22, 1992
(907]~~
696-2417
ADEQUACY TEST
Legal Description; Lot 25, Heritage Heights Subd.
Date Performed; February 21, 1992
Septic Tank Size: 1000 Gal., 2 Comp., Steel Tank
Absorbtion System:Deep trench, 36' x 5' effective depth.
Soils Rating: 100 SF/BR
Daily Design Flow: 3 BR x 150 Gal/day/BR = 450 Gal/Day
(DHHS Records)
(DHHS Records)
(DHHS Records)
Test:
675 gallons of water were introduced into the absorbtion system in
a 1 hour 50 minute period.
Results:
The system accepted 150% of the daily design flow with a 0.54' rise
in the monitor tube liquid level. The total liquid level rise dropped
to the original Ievel within 1 hour.
Conclusion:
The absorbtion system is currently functioning adequately.
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
~NALYSIS i%ESUITS ~er INVOICE ~3 51322
Che~llab Ref.$ 92.0693 Sample ~ i Ma'cr~x:
FAX: (907) 561-5301
Client Sample ID L25 HERITAGZ H~IGHTS Clien~ Nsme :DAVID DAYTON P.E.
PWSID · UA ClJ. eI~ Acer :DAVIDDA
ColIected : ~EB 21 92 ~ 09:30 hrs. B?O~
Receive~ : FEB 21 92 ~ 13:20 hfs Req$ ·
Preserved with : AS REQUIRED O~dered By
PO~ :NONE RECEIVED
~nalysl~ Completed : ~ER 24 92 Send Reports
1)DAVID DAYTON, P.E.
Laboratory Supervisor : 8TEPIiE)) C EDE
/
Paral~mter Results Units 14et hod Allowable
...............................................................................................................................................................................
NiTRATE-I{ 3.2 mg/1 EPA 353.2 10
Sa~npie ROO'.CINE SAI4PL[3 COLLECTRD BY: D.R DAYTON.
Re~nark~.
1 'rests Perfo¢~,~ed See Special Instructions J~hove U),-~O~availabie
Nf~= Not An~).yzed LT.,Less Than. GToGrea~er Tlmn
Member of the SGS Group (Soci~t6 G6n6rale de Surveillance)
:!:i; !::!;: !~ ~;i ':.:' ~! ;'~:: ?; DEPARTMENT iOF; HEALTH AN~D ENV!R:ONMENTAL PR O~E~TIO~N ?i~:!!' i ':
:i; ~: ::. '::;:; i DivISION OF ENV RoNMENTALHEALTH ~;;:?ii:~;
: CERTiFiCATE OF. NSPECT~oN FOB ,E~LT':AOT'OR T¥ ApPRoVA'~ i::: :
'' O~ oN-s ~ sEWE~ ~N~ W~E~ ~C~UTy: : ~: ~ '
~ : 264-4720 ~?~:: ' := ~ ~ ~. ~.:
~ , ::' :::: Application: Date : :
. . . : .:::
GENERAL INFORMATION ' - '
(a) Legal Description (include lot, block, subdivision, section, ~ownship, range)
Lo~ 25 ~e~age ~e~gh~s Subd~v~s~o~ :
Location (address or directions) " :
9200 Spruce Knoll Circle
(b) Applicant Name Phil Powelson Telephone: Home 346-3354 Business 562-2244
Applicant Address 9200 Spruce Knoll Circle~ Anchorage 99516
(c) Applicant is (check one): Lending institution []; Owner/builder [~ Buyer []; Other [] (explain);
(d)
(e)
Lending nstitution Alaska Pacific
Address
Telephone
Real Estate Corn party and Agent
Address
Telephone
(f) Mail the HAA to the following address:
2.' TYPE OF RESIDENCE
Single-Family [[~x Multi-Family []
Number of Bearooms three(3)
Other
WATER SUPPLY
Individual Well [~x Community [] Pu blic [] . .
Note: If community well system, must have written confirmation from the State Department of Environmental Conse rvatior
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite t~xx Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Depaament of Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2
5:'~i ENGINEERING FIRM PROVIDING~.,~SPECTIONS,~ESTS, F!LE SEARCH,:DAT~':AND.!NFOR~ATION:'?,: ~':' ; ~'~:': '
iiil AS C~rtified by my seal affixed hereto and as'of the ~alidati~n dat~sh°Wn bel0W/i Verify that m~ir~ve~tigaii°n ~f 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 ve~rify 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 ali Municipal and State codes, ordinances and regulations in effect on
the date of this inspection.
Name of Firm Telephone
Address
Date
This department has received written confirmation from the engineer
regarding the Conditional Approval of April 11, 1986.
The corrections have been accomplished and an inspection has been
completed by the engineer. The subject property meets with Mun£cipal
standards and is now.approved.
DHEP APPROVAL
Approved for three (.3)
Approved
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental 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 Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work. '--.
Page 2 of 2
72-025 (11/84)
NHAWTHORNE-ENG]{NEEKING
7127 OLD SEWARD HIGHWAY
ANCHORAGE, ALASKA 99502
907-$44-47 ! I
July 8, 1986
Alaska Pacific Bank
101W Benson
Anchorage, AK 99510
Attn: Shelly Reese
Re: Powelson, Lot 25, Heritage Heights Subdivision
Dear Ms. Reese:
I have inspected the "sump" pipe which was recently
installed on the above lot's septic system trench. This
installation satisfies the deficiency noted on my inspection
report of 4/7/86.
Sincerely,
Neil Hawthorne, PE
NH:ck
MUNICIPALITY OF ANCHORAGE
dEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
GEF~TIFICATE 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 [~14~ ~¢ ,.~e I ~n ~ Telephone: Home
Applicant Address
Business
(c) Applicant is (check one): Lending Institution []; Owner/builder..~; Buyer []; Other [] (explain);
(d) Lending Institution
Address
Telephone
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single~Far~ily ~ Multi-Family []
Number of Bedrooms ~
Other
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 the legality and status.
~::;:' ;i !'"';!~'i~!i~'~l~J"'., ,.,.,.. Public ~ Community ~ Holding TankU
,'.',; .:~?~:~,~ - ~, .,~ ~': If community well system, must have written confirmation from the State Department of Environmental Conservation
"-:', ((;::¢ttesting to the legality and status.
Page 1 of 2 /2-025 (11t84)
Eb~:.~7.~.~.~Rli~iG F)iiM ?FH)ViDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As c~rt f ed by my' ~?~ ~ffix~d hereto and as of the validation date shown below, I verify that my investigation of this Health
?,~ iArJ r ~y ~pp~ ~t ~ shows that ~he on-s te water supp y and/or wastewater disposal system is safe functional and adequate
[or ~h~ number of bedrooms and type of structure indicated herein. I fu~her verify that based on the information obtained
from U~e M.rfic~p~ itv of Anchorage files and from my investigation and inspection, the on-site water supply ~nd/or
,,¥~st~w~ter d sp~ s~l system is in compliance with all Municipal and State codes, ordinances, and regulations in effect
the d~te of this inspection.
I%~a, ~e o~ Firm ___/~¢=.~I~¢Y'~ ~--~j ¢, Telephone ;3 4- · ~'~ II
WAi;,.f~, ~IELL NOI'E: '~his Health Authority Approval inspection merely
~ ~v~-ifies i-i~at the subject water well produced 150 gallons per
bedroom o;" more on the date of testing and that certified laboratory
tests showed no presence of coliform bacteria in a sample of that
water. No warantee or certification is expressed or implied
concerning the long term adequacy or safety of the water supply.
ON-SITE SEWAGE DISPOSAL SYSTEM NOTE: This Health Authority Approval
inspection merely certifies that the subject on-site sewage disposal
system accepted at least 150 gallons of water per bedroom on the
date of testing as determined by methods approved by the Municipality
of Anchorage Department of Health and Human Services. No warantee
or certification is expressed or implied concerning the long term
adequacy of the on-site sewage disposal system. Construction data
reported on buried system components is from MOA files and was
not verified during this inspection.
Approved for
Approved ~ Disapprove~ Conditional
Terms of Conditional Approval e)
CAUTION
The Muncipality of Anchorage Department of Health and Environmental 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 Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
PaQe 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: /'-- ~ ~''
ENVIRONMENTAL PROTECTION
, R,ECEIVED,
WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth _~0 Cased to
Static Water Level
GasJng Height Above Ground ')
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
If A, B, C, D.E.C. Approved (Y/N)
Depth of Grouting
Pump Set At U~' ? I,~/.,¢~
Sanitary Seal on Casing (Y/N) k//
Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole /U/
Water Sample Collected by
Water Sample Test Results
; On Adjoining Lots
! / ~ ' On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on
; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed ~-~X~;/ ~/
Standpipet (Y/N) )/ Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N) /1,,/
Holding Tank High-Water Alarm (Y/N) ,A--'///~
SeParation Distances from Septic/Holding Tank:
To Water-Supply Well ,/E')f¢) /
To Property Line ,-,'-'2~)/-¢~
/
To Water Main/Service Line /w .~,O
Course -/v///~
Size J E)E?O No. of Compartments ~
y Foundation Cleanout (Y/N) r~
Date Last Pumped ¢¢' - zi/---~ ~'¢
; for
Temporary Holding Tank Permit (Y/N) /0{//¢ __
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field ~(¢
Depth of Field _ ,~--/
Gravel Bed Thickness 5 /
Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well / / ;3
To Building Fot~ndation '~ a-
To Water Main/Service Line ~> z~O !
To Stream/Pond/Lake/or Major Drainage Course
To Property Line ..~E.~ +-
To Existing or Abandoned System on
!
; On Adjoining Lots ~ IOo
To Cutbank (if present) ~/.,4
To Driveway, Parking Area, or Vehicle Storage Area
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Page 2 of 2
72-026 (11/84)
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have, check, ed, ye, rifted, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ,;'~-~'~'L / ,~,/--¢¢~4'~~ Date
Company MOA No.
Receipt No. ~? q'~ ~ G
Date of Payment ~ .?_~
'
Amount: $ ~ ~o~
t-r~, ! DAT~E RECEIVED
INSPECTION APPOINTMENTS
TIME TIME ~ TIME
DATE ~ DATE DATE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street-Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be pro~ess~d, Please allow ten (10) days for processing.
MAILIN~ A D~R'ESS
PROPERTY RESIDENT (If different from a PHONE
..ova.
MAILING ADDRESS
3. LENDIN~INSTITUTION [ PHONE
4. REAL~O ~/A~ ENT PHONE'
MAILI~Q AOORE88
LEGAL DESCRIPTION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
I~ SINGLE FAMILY [] One [] Four []
[] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
Other
7, WATER SUPPLV
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*~
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6~79) t] :
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE F~ THREE E~ 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
[] I N DIVI DUAL/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/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL TO:
I
Absorption Area to nearest Lot Line
5. COMMENTS
[~APPROV ED FOR .~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
72-010 (Rev. 6/79)