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Home My WebLink AboutHERITAGE PARK BLK 1 LT 14A ~,_ ,, 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 [] UPGRADE LOCATION ~: F NO. OF BEDROOMS¢ J Well j Absorption area Dwelling, -~' PERMIT ,O~.~ ~, DISTANCE TO 0 /0 / ~ ~ No. of compart~nts N ~ Manufacturer Ma Liq. capacity in gallons Inside length Width Liquid depth { 00 O IF HOMEMADE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO, O z ~ Manufacturer Material Liquid capacity in gallons O Well Foundation~ Nearest lot line ( PERMI~g'~ ~2 ~ Z NO. of lines Length of each I~e~' Total leng~i,es Trench width Distance --~ /~) /SO ' inches effectiv~o~tion ~ ~ ~ Top of tile to finish grade ~-/ Material beneath tile Total area Length Width Depth PERMIT NO, ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: Depth Driller ~ Distance to lot line PERMIT NO, m Building foundation Sewer line Septic tank Absorption area(si ~ D~STANCE TO: OTHER SOIL TfiST BATING A~~ DATE LEGAL 72-073 IR~ 8) ~ F'EF.:M I T i'.,tG: b ~~~--=- ][ TE bE~--~EF-: F EFt' f'l ][ T RF'F'L I C:FINT LOCRT I ON LEGRL [:,E',,,'CON ENT. INC. ._4tt OLD SEWRR[:, HW"¢. LOT -'14 BLK i HEF.:ITFIGE PFIRK SUB LOT SIZE 56:L-±OB2 99'9999 S;~I_IRF'E FEET T'T'F'E OF SOIL RBSOF.:F'TION '=;'T'STEM IS: TRENCH I"1R::.:;If"ILII"I NLIME:ER OF BE[:,ROF$1S = 3: SOIL RRTING ,:;'_=,Q FT,-"E:R)= THE REI_.-.!UIRED SiZE OF THE SOIL HE, z, URFTILN S'-,"STEM IS C,E F" T ~-t= 1 E~ LE~-~GTH= ~:'2 GRR%-'EL [:. E F' T H =: 6 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINF'IEL. D. THE DEPTH OF R TRENCH OR PIT IS THE DISTBNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). F'ERMIT RF'PLIE:RNT HRS THE FEz, F_N:,tE, tLITT TO INFORM THIS DEF'RRTMENT [:,UF.:ING THE INSTRLLRTION INSPECTIONS OF RNV WELLS RDJRCENT TO THIS PROF'ERT"r' RND THE NLIMBER OF RESIDENCES TI"IRT THE WELL WILL SERVE. T~.lEt (: 2 ::. i t'-t'_-]F'EC:T -t- Ci~-l'_-] RF-:E F..: FL.-;-.~L~ ][ BBCKFILLiNG OF RN'¢ SVSTEM WITHOUT FINRL INSF'ECTION RND RPPF.:OVRL B'¢ THIS DEPRRTMENT WILL BE SUE:JECT TO F'R]SECLITION. MINIMUM DiSTRNCE BETWEEN R WELL RND RNV ON-SITE SEWFtGE DISPOSRL SVSTEM IS "fOE1 FEET FOR R PRIVRTE WELL OR ±5E1 TO 2E~E~ FEET FROM R PUBLIC WELL DEPENDING UPON THE T'¢PE OF PUBLIC WELL MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R F'RI',,.'RTE SEWER LINE IS 25 FEET RND TO R COMMUNIT"r' SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MR"r' RPPL"/. SPECIFICRTIONS RND CONSTRUCTION [:'IRGRRMS FIRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. F'EF-:I'I ][: T E::-,~F' ;[ F.:E'--]] [)EC:Ei'-IE:EF-: 2;1.. 1L-¢~ .-- I CERTIFV THRT ±: IRM FRMILIRR WITH THE F..Eb. LIIF..EMENT_, FOR. uN-=,ITE SEWERS RND WELLS RS '_-]ET FORTH B'¢ THE MUNICIF'RLIT'¢ OF RNCHOF.:RGE. 2: I WILL INSTRLL THE _-,~_-TEM IN RRCOF.'.[:,RNCE 1.4ITH THE F:O[:,ES. 2:: I UN[:,ERSTRND THRT THE ON-SITE SEWER S'¢STEM I"IRV F.'E;L IRE ENLRRGEMENT /IF' THE RESiDENF:E/~S REMO[:,ELE[:, TO ~I~.JE:LI_I[:,E MORE THRN 3: BEDROOMS. 'Al MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOC [] PERCOLATION TEST LEGAL DESCRIPTION: L o+ 14 1 2 3 5 6 7 8 9 .._ 10 11 12 13 14 15 16 17 18 19 2O COMMENTS PERFORMED BY: 72-008 (6/79) SLOPE o ,~ o' /5' Zo' ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop ~-,.. .~- PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN 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 1. GENERAL INFORMATION Complete legal description Lot 14A; Block 1; Heritaqe Park Subdivision Location (site address or directions) Property owner. ".pa,T] r.n~aki~ Mailing address 19744 Ivy Home Circle Eaqle River, AK Day phone 19744 Ivy Home Circle Eagle River, AK 694-7377 99577 Lending agency Mailing address Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 '~ TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water 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 NOTE: x~x Public sewer 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 STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed hereto and as of the validation date shown below, I verify that rny investigation of this Health Authority Approval application 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 verifythat 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 S & 5 ENGINEERING 170;~¢, Eagle Riw, Lo,~,. ~&-J ,%~c., 204 Phone L, ~;i b~ - ~ ~'1 '7 ':71 Address Eagle River, Alaska 99577 Engineer's signature DHHS SIGNATURE ,','. ~- ' ~ ~ ,",-'s'~/ ~ Approved for T/~'/~ 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 BI-IHS 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. 72-025 (Rev. 1/91) Back MOAtY21 RECEIVED Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVI .~d~.,~ 2 6 ]998 Environmental Services Division MUNICIPALITY OF ANC ~ :HO~AGE 825 L Street, Room 502 · Anchorage, Alaska 9950~9~R~3~3~i~L4~ DIViSiON Legal Description: L~T ]~fA Health Authority Approval Checklist ~0~.y. t <j~)~w~,'J Parcel I.D.: A. WELL DATA Well ty~, ~ If A, B, or C, attach ADEC letter. ADEC water system number ~-~ Log presen (Y~,, Date completed Total depth~ Cased to Casing height (above ground) Sanitary seal (Y/N) ~ Wires properly protected (Y/N) FRO~ AT INSPECTION Date of test Static water level ~g.~p~ Well production ~ .m~......~ g.p.m. WATER SAMPLE RESULTS: Coliform Nitrate Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~/~'~/~ Tanksize /O~ Number of Compartments ~-- Cleanouts Foundation c!eanou~) u/.~5 Depression ('1~) I,~o High water alarm (Y~) Date of Pumping ~/,~'~ ./'~i Pumper C. ABSORPTION FIELD DATA Date installed ~,/Io/~ Soil rating (g.p.d./ft~ or fF/bdrm) ~'(o '~ System type Length '~E, / Width '~ ;'/ Gravel thickness below pipe ~'~, ~otal depth ~l~w~ Effective absorption area 3~ ~L'~ Monitoring Tube present (~). ~ ~$ Depression over field (Y/~ Date ofadequacytest 5///~'~ ResultS/Fail) /;~$- For T~I~ bedrooms Fluid depth in absorption field before test (in.); ~1"~ ~ Immediately afterZ~ ~/~gal. water added (in.): Fluid depth 7o" (ins) Minutes later: / (~ (; Absorption rate = -~5'O-F g.p.d. Peroxide treatment (past 12 months) (Y/N) ~o,J e. ~.~ If yes, give date 72-026 (Rev. 3/96)* LIFT Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested Size in gallons el at* "Pump off" level at*. *Datum% SEPARATION DISTANCES SEPAR~NCES FROM WELL ON LOT TO: Septic/holding tank on Iot~'~"~_......,~ On adjacent lots Absorption field on lot ~ On adjacent lots Public sewer main P~nhole/cleanout Sewer/septic service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~ Property' line ¢~ i. ~ Absorption field Water main/service line 10' ~ Surface water/drainage {0o' )¢ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line It)' ~' Building foundation [o u¢ Water main/service line f0 Surface water I(~O~ ~ 10' ~ Driveway, parking/vehicle storage area Curtain drain ~.¢,0~P~ Wells on adjacent lots ,2,.~O ' ;~' ENGINEER'S CERTIFICATION "' I certify that l have determined thru field inspections and review of Municipal recorj~.4~?~'~CCt~.~.~ in conformance wi~ MOA H~ guidelines in effect on this date. Signature - -- ~ , Engineer's Name ~6~'7 C: ¢p~4~ HAA Fee $. ~(~)o-OC~ Date of Payme,t Reoe pt Num ,er 0 Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 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) (b) (c) Location (address or directions) Applicant Name ~ Applicant Address Telephone: Home Business f~ ~-~..- f.J¢~ Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other ~ (explain); (d) Lending Institution ~,~1~:;~:¢,"~,~ Address ¢¢~' ¢'~ f---~ '~~ (e) Real Estate Company and Agent ~ Address ~ Telephone ~ ~ (f) ~HAA to the following, address: - 8RB 106~ · TYPE OF RESIDENCE Single-Family,[- Multi-Family [] Number of Bedrooms '"P Other WATER SUPPLY Individual Well [] Community [] Publicl~ ' Note; If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite ~ Public [~] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 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 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 ~ ~ ~ E..'~GINEERI~ ,,, ~m Telephone Address ',~;, ,~1,~ ~IV~R~S}~ ~1 Date ...... ~¢~ DHEP APPROVAL Approved for '~e'~(,-5~2 bedrooms by Approved /~/ ' '- 'Disapproved Terms of Conditio,nal Appro~ai Conditional Date '~'~ 0 '~4-'¢ 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 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: Well Classification Well Log Present (Y/N) Total Depth Static Water Level Cased to Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/IC. eldirtg--Tank on Lot 2---~,*.¢ To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole If A, B, C, D.E.C. Approved ~tN) Date Completed. Yield De. pth of Grouting / Pump Set At ~4 //~,Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Water Sample Collected by Water Sample Test. R~-Iis ...... ; On Adjoining Lots ; On Adjoining Lots Nearest Public Sewer ~o/1~earest Sewer Service Line on Lot ; Date B. SEPTIC/H~)C'-DfN't~TANK DATA Date Installed tz2--~(f')~;?~'~_- Size *~ ~ No. o?~ompartments.. ~ Standpipes ~N) Air-tight Caps ~q) Foundation Cleanout (~N) Depression over Tank (Y~ Date Last Pumped ~ _,1~:~_ ~, Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/~ank: To Water-Supply Well '~..,cr~e~ I--~ To Property Line ~ ~ ~ ~' To Water Main/Service Line \ c, t 5r Course · for Temporary Holding Tank Permit (Y/N) 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 ~ - ~C~ Width of Field ~ Square Feet of Absorption Area Depression over. Field (Y/(~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation '~' Lot ¢'~ ~ Type of System Design Length of Field ~""~'~. ~ Depth of Field '~ ~ Gravel Bed Thickness r'~ Standpipes Present ~,N) Date of Last Adequacy Test To Water Main/Service Line t, ~ [J¢ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area : To Property Line To Existing or Abandoned System on On Adjoining Lots To Cutbank (if present) ~,~.'D/,~. Comments D. LIFT STATION Date Installed Dimensions Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) 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. Date of Payment %=f~L% .. ~% Amount: $ ~ ,¢~ Page 2 of 2 72-026 (11/84) 1. General Information Lo~t~ion (add, e/ss or direct/iQ.ns) / (b) Applicants N~_ ~4 ~ Applicants Ad~oss X-~// (c) (d) MUNICIPALITY OF ANCHORAGE DMSION OF ENVIRONMENTAL HEAL%~H DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE Application Date 3--/.~-'8~/ loA,! blocR, subdivision, section, range ) /--/~/~/~/~ ~,~/g/r cPf'~ township, Telephone ~/-/O~p g Applicant is (check one) Lending Institution ~; Owner/builder~ ~ Buyer ~; Other [ I (explain); Lending Institution Telephone 4 (e) Address Telephone _Type of Nesidenoe Si ngle-Family~ Number of Bedrcoms 3. Water Supply Multi-Family Other (describe) Note: If co,'~,'.~nity well system, must have v~i~ten confirmation frcm the State Department of Environmmntal Conservation attesting to the legality and status. Is the well adequate for the number of bedrccms specified in this HAA~//~ sewage Disposal Onsite ~ Public ~--~ Community ~ Holding Tank ~-~ Is the wastewater disposal system adequate for the number of b~droc~s ) [Page 1 of 2] 2-15-84 5. Engineerinq Fi_mn Providing Inspections, Tests, Data snd Information I certify that'~'~vet_~heck~_d, verified, c~ conforma, d to all MOA HAA Guidelir~s in effect on · ,,:~- 'SI~,':; '~'~9~.,. ........... signed by Date 6. DHEP Approval Approved for Approved ~ ( ENGINEER SEAL) 3 beclrccras By Disapproved ~ Conditional Te~s of Conditional Approval The Municipality of Anchorage Dapa~tm~.nt of Health and Environmental Protection dce. s not 9uarantee the continued satisfactory perfomnance of the water supply and/or the wastewater disposal system. This approval indicates that, as of the validation d~te sh(7~Tl above, based on the data and information furnished by an engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional for the numbe~ of bedrooms and type of structure indicated. (D~EP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] 2-15-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALT~ ALYi~ORITY APPROVAL (HAA) TT OF Well Classification Well Log P~esent (Y/N) Total Depth Static Water Level Casing Height Above Ground Electrical wiring in Conduit (Y/N) Separation Distances f~cm Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Neacest Public Sewe~ Line C leanout/Manhole Wate~ Sample Collected By CHECKLIST - FEBRUARY 1984 B, ~ C, D.E.C. ~p~ove ) Date ~leted Yield Cased to Pump Set At D~pth of Groutinq Sanitary Seal on Casing (Y_/N) Dep~essionA~oundWellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest SeweF Service Line on Lot ; Date WateF Sample Test Results Cc~a~nts SEPTIC~ANK DATA Date Installe.~d 6~2A~ Size /~..~ No. of Ccmpa~tm~nts y~..~-- Stan~i~s ~ / / Ai~-tiuht Caps ~ F~ndation Cleanout ~p~ession o~ Ta~ ~ ~te ~st P~d ~~ P~ing~intenan~ ~n~a~ ~ File %~)~; fo~. ~ Holding Ta~ High-Wate~ Ala~ (Y~)~/~ . ~a~ Holdi~ Tank ~t ~ Sep~ation Distan~s ~ ~ptic~olding Ta~: To Water-Supply ~11~/~;~ To ~ildin~ F~ndati~® ~ /~ To P~operty Line ~O l_j_ / To Water Main/Service Line _.~L~ ,7~- Course [Page 1 of 2] Zo 7~ I~/{ ,Z~,/C- / 2~15-84 ABSORPTION FIELD DATA Soils Rating in Absorption Strata /~_~,_~ Type of System Design Date Installed ~.//~/~-~ Length of Field 3~,~ Width of Field ~ CD " Depth of Field // / · _,/ Gravel Bed Thickness ~ // Squa~e Feet of Absorption A~ea ~/~,~/~,~ Standpipes P~ese~t Depression ove~ Field (~ Date of Last Adequacy Test / Results of Last Adequacy Test /I// /~ Separation Distance f~om Absorption Field: To Water-Supply Well ~//~/l~//,-'V-~/ To P~operty Line /~ / ' To Building F6undation ~O / To Existing or Abandoned System cn Lot /~O/%3/~- ; On Adjoining Lots ~-~ / To Water Main/Service Line ~ /~ To Cutbank( if present) ' /C/ /'//~ To Stream/Pond/Lake/or Majo~ D~ainage Course /~z~/iJ~ To Dlriveway, Pa~ing A~ea, or Vehicle Storage Area ///~J ~-~?0~.~-~ D. LIS~f STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for t Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Elect~ica! Codes (Y/N) Counts ~ets MOA Check Permitted Bedroom Rating Against HAA Request verified, or conform~=d to all MOA HAA Guidelines in effect MOA No. 2-15-84 DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA g9501 BILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 To Whom it May Concern: r__ 4 According to records on file in this office the .~,~,~.Z~/V/Jl'O// Water SYstem is in compliance with the State Drinking Water Regulations Sincerely, 3/IUNICIPALIT'r' OF ANCHoI~,oE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION RECEIVED APPLI( ,: .NT FILLS OUT UPPER HAL .., ONLY ~'~ Phone · Property Owner ]]evcon Enterprises, Thc. Mailing Address 54'11 Old Seward Hwy, Anchorage, Alaska Zip Code 99502 561-1082 Buyer Eugene & Roberta Ensor Address NHN Ivy Home Circle, Eag~ River, Alaska zip Cods 99577 Phone Lsnding ~nstitution Alaska Pacific Bank 101 West Benson, Anchorage, Alaska zip Code 99503 562-6100 Addrsss Phone Realty Co. &Agent Century 21, Heritage Homes / Tom & Carolyn Szymanski 207 East Northern Lights Blvd., Anchorage, AK zip Code 99503 276--1333 Address Lega~ Description Lot 14A, Block 1, Heritage Park, replat of Lot 14, BlOck l, Heritage.~ Park street Locatim NHN Ivy Home Circle, Eagle River, Alaska' ~-krepzat i983) Type of Residence ~ Single Family [] Multipte Family No. of Bedrooms 3 [] Other Water Supply [] Individual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells dritled prior to that date, give well depth (attach log if available). Community Public Utility Sewer Disposal ~ Individual Year Individual Installed: ].983 [] Public Utility When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: Q- A133]ll ~' H.CIY-3H JO ( ) APPROVED BEDROOMS *CONDITIONS OF APPROVAl-~'~lL)H~bl~'~' ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size 72-023 (3182)