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HomeMy WebLinkAboutLAKEWOOD HILLS #3 LT 32 GI?-'~'TER ANCHORAGE AREA BOROI'~'~H D~.~'ARTMENT OF ENVIRONMENTAL QUALI~ .i 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING ADDRESS /"¥~/'/.J~ .,,~ "~"~.'~f/~""/~' .__PHONE 7'~"~-~ SEPTIC TANK: DISTANCE FROM WELL .~.~ LIQUID CAPACITY LEGAL DESCRIPTION GALLONS. NUMBER OF MATERIAL 6" ~ ~¢: ~/r'- '/~--'~,,'''~c~'~ COMPARTMENTS INSIDE LENGTH ~ INSIDE WIDTH ./ LIQUID DEPTH SEEPAGE SYSTEM: SEEPAGE PiT: NUMBER OF PITS__ / LINING MATERIAl NEAREST LOT LINE OUTSIDE DIAMETER ~ OR WIDTH /,'~ . LENGTH '~'~ , DEPTH ~'~/'~.-.~.~'"~ DISTANCE FROM WELL ,z~'~'~,,.-~.-'~-').~¢~--/'~/~' , BUILDING FOUNDATION TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) "~"'~ ~ SQ. FT. TILE DRAIN FIELD: /4///_9 DISTANCE FROM WELL NUMBER OF LINE~S~ ABSORP ONe'AREA DISTANCE BETWEEN LINES SQ. FT. LENGTH OF EAC~H~LINE DEPTH: TOP OF TILE TO FINISH GRADE / , NDATI NEAREST LO~' LINE TRENCH WIDTH TOTAL LENGTH , OF LINES. IN. TOTAL EFFECTIVE DEPTH oF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE__ WATER SAMPLE , NEAREST OTHER .C.-~.~-- , SOURCES WELL: ~:~.~.¥.~/~s~._.r~:~/~*/,..~..~/.~'~-...~,~--- / DISTANCE FROM TYPE ,,/~.,,~...~.~-~z';'~ , DEPTH . BUILDING EOUNDATION~"'~'~ NEAREST SEPTIC SEEPAGE LOT LINE / , SEWER LINE ~ ., TANK ~ , SYSTEM ~ , CESSPOOl. DIAGRAM OF SYSTEM DISTANCES: · GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3500 TUDOR ROAD POUCH 6-650 ANCHORAGE. ALASKA 99502 TELEPHONE 279-86S6 SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT NAmE Of APPLICANT INSTALLATION LOCATION iNSTALLATiON DP: SEPTIC TANK TYPE AND S[ZE Of PACILITY TO BE SERVED PINANCEO T.ROUG. SOIL TEST RESULTS SEEPAGE PIT y , DRAIN fIELD OTHER NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL COMPLETION DATe ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT ~ ~0¢ , DRAIN FIELD WELL TO SEPTIC TANK DRAIN FIELD SEEPage PIT /~ ALSO CONSIDER AREA WELLS. SEEPAGE PIT WATER MAIN TO SEPTIC TANK DRAIN FIELD SEPTIC TANK. ~¢' ., seePAGE PIT /~/ , DRAIN FIELD . TO RIVER, LAKE, STREAM, CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIiT FITTED WITH Airtight REMOVABLE CAPS. DIAGRAM OF SYSTEM GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. LICENSED DESIGNER 1 CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA/~/~H ORDINANCE NO. 28-68 AND THAT THE ABOVE DAT~/~-/-' - ~{~,/¢7/ APPLICANT'S SIGNATURE 10 12 14 ............. ~*~ .I CASE' Pe~¢o~med Foe ~azvey ~ic~et Leg ..... r - ~---~ ........................ Date Pe~fm-med 8/23/71 Deoth ........................ ~e~coJ at ~,~n ~e ~:;-- ~ ~ Sand and Silt M~ 6~ Gray Gravelly Sand (ow) - (sw) Was Ground Water Encountez,ed? No if Yes, AG f/hat Depth Reading Date ~- -~c ~'~ :Fi me ~ ~"~ '.rime Depth To H20 Net Dz~op Data Certified By: National Testing Services, Inc. MUMUPALITY O r':� .,,`:j _•yam civ, tf.� Development Services Department On -Site Water & Wastewater Section Parcel I.D. 015-134-11 Certificate of On -Site Systems Approval Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: 2 1. GENERAL INFORMATION Complete legal description Lakewood Hills Sub, #3 Lot 32 Location (site address) 7540 Upper O'Malley Road Current property owner(s) ,Jerry & Sheila Ballstreri Day phone (907) 830-5258 Mailing address 7540 Upper O'Malley Road, Anchorage, AK 99507 Real estate agent Day phone 2. TYPE OF DWELLING: ❑ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Q Private Septic Q Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 55 0 Waiver Fee $ Date of Payment y o�� 0� Date of Payment Receipt Number. 0 `731�, Receipt Number COSA # 05 C _� 1 H � Waiver # 5. 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, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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 (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller Date 4/14/21 .�4�pF q�gsll� i y�P •n -I 6. DSD SIGNATURE �� l/ System #1 Approved for bedrooms �r aenjarni}�Schi�Iler'\- System #2 Approved for bedrooms1�FVIP• CE 12592 Disapproved k1 ROFESSION Conditional approval for bedrooms, with the following stipulations: vvrrr F_ r. r%rvv By: Original Certificate Date: The Municipality of Anc rage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist yellow sheet COSA Checklist Legal Description: Parcel ID: If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample Comments __________________________________________________________________________________ B. TANK DATA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank Standpipes/foundation cleanout per record drawing Date of pumping C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA ______________________ Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Code-required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Adequacy test date Results Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: *Testing confirmed that the tank was not leaking, and a camera inspection confirmed that the outlet baffle was intact. Lakewood Hills Sub, #3 Lot 32 015-134-11 1.9 1972 N/A 120 40+ 9.15 18 Forge Engineering 6/3/20 85.6 4/20/21 No well log. Well depth and casing depth taken from original COSA paperwork. *49 Septic/Concrete 54 11/18/19 Log Crib 1971 6/3/20 4 9.5 12 **621 24 1440 12 >600 None N/A COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10’ Yes if No ft Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft F. ENGINEER’S COMMENTS G. ENGINEER’S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. May 5, 2021 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 5/5/21 Subject: Lakewood Hills Sub #3, Lot 32 – Upper O’Malley Septic justification Dear On-Site Services Engineer: The septic system was installed in 1971 on the subject lot for a 4-bedroom home. The system consists of a 1250-gallon concrete tank and a log crib. Testing and inspection of the system indicates that the tank is not leaking and that the crib is performing adequately for a 4-bedroom home. The tank is located approximately 75’ from the well, and the standpipe for the crib is 105’ from the well. We do not know the exact orientation of the crib or how far it extends underground toward the well. Our investigation into Muni records revealed that the system was approved by the Municipality for 50’ separation from the well to the septic tank and 100’ from the well to the crib. In 1987, a COSA was issued noting the separation of 105’ from the well to the standpipe for the crib. There was no waiver required for possible well encroachment at that time. A portion of the tank as well as an unknown portion of the crib may be located under the driveway. However, the septic system was installed before 1986, when the code was changed to prohibit the installation of septic systems under driveways. The septic has remained in service since installation with no failures. In the recent past, a double-cleanout was installed between the tank and crib to fix a blockage that had occurred, but since then, the owner has experienced no trouble with his septic. In conclusion, we feel that the septic system meets all municipal requirements, and is working adequately to support a 4-bedroom home. Sincerely, Benjamin Schiller, PE May 11, 2021 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 5/11/21 Subject: Lakewood Hills Sub #3, Lot 32 – Upper O’Malley Well inspection Dear On-Site Services Engineer: On the April 13th, a water sample was taken for a COSA for the subject property. The results we received show the nitrate levels to be at 9.15 mg/L, prompting the need for an inspection on the well to check the integrity of the well casing down to 40’. A camera inspection was performed on April 27 th by Anchorage Well and Pump Services. No perforations were observed in the casing or water intruding above 40’ or otherwise. Our observations of the inspection have led us to conclude that the well is not being contaminated by groundwater between 0’ and 40’. We have a copy of the recorded inspection available upon request. Sincerely, Benjamin Schiller, PE MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907-343-7904 On-Site Water and Wastewater Section Fax: 343-7997 www.muni.org/onsite Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org Nitrate Advisory Certificate of On-Site Systems Approval # OSC211186 Subdivision: Lakewood Hills #3, Block: , Lot: 32 A water sample revealed a nitrate concentration of 9.15 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached “Nitrate Fact Sheet” for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. UPPER O'M ALLE Y R O A D R=308.10'L=161.85'N20° 15' 00"E 126.08'N16° 15' 00"W 77.07'N 56° 49' 00"E 182.39'16.4' SHED 1 9.6'19.6'41.3'41.3'19.6'19.6'LAKE HIDEAWAY7%7%EXISTING HOUSELOT 32 LOT 31 LOT 33 10' UTILIT Y E A S E M E N T 2 1 .5 '50'50'31.8'66.7'54.3'56.2'38.3'86.2'LOT 32, LAKEWOOD HILLS SUBDIVISION NO. 3 AS-BUILT SEPTIC STANDPIPE WATER WELL FENCE Asphalt Concrete Overhang Wood Deck LEGEND: NOTE: THIS DRAWING SHALL NOT BE MODIFIED FOR USE AS A PLOT PLAN WITHOUT THE EXPRESSED WRITTEN CONSENT OF LCG LANTECH. DRAWN DATE: DRAWN BY: SCALE: CHECKED BY: 6/18/2020 SC AP 1" = 30' PLAT: WORK ORDER: 20033 P-342B FB/PG: 817/58 GRID: SW2540 REF: 92L646A LEGAL DESCRIPTION: ORDERED BY: JERRY BALISTRERI SURVEY CERTIFICATION: LCG LANTECH, INC HAS CONDUCTED A PHYSICAL SURVEY OF THE PROPERTY AS SHOWN ON THIS DRAWING AND CERTIFIES THAT THE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO ENCROACHMENTS EXIST OTHER THAN NOTED. EXCLUSIONARY NOTE: IT IS THE OWNERS' RESPONSIBILITY TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, RESTRICTIONS OR RIGHT-OF-WAY TAKINGS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION, FOR ESTABLISHING PROPERTY LINES, OR FOR PLOT-PLAN PURPOSES. 250 H StreetAnchorage, Alaska 99501 Survey Department Phone 562-5291 Mainline Phone 243-8985 AECC 668 PARCEL #: 015-134-11-000 ADDRESS: 7540 UPPER O'MALLEY RD. POWER POLE MUNICIPALI'FY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property Owner'~k~'~'' ~dc. K44E[EI'(. Telephone: Home Mailing Address i~_,~-~.-~O 0/¢~/¢~- ¢¢;)/'f,C~//~y /'E¢~..~-O/ (c) Lending Institution Telephone idusiness Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the followino address: or: Check here BI, if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family ~ Number of Bedrooms WATER SUPPLY Individual Well.~ Community [] Public [] Note: If corem unity welt system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 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. Page I of 2 72-025 (Rev 8/86) Front '::,p o,~ s,.~eeu!lSue leUO!SSejoJd eq~, u! SUO!SS!LUO .~o s Jo.ua Jo,t elq!suodse.~ ~,ou s! eOeJoqouv ,to/q.!led!olunbt Sql 'penss! s! e~.ea!,t!pea e e.~o~.eq e~.ep aZAleUe .~o suo!l, oedsu! ionpuoo ~.ou ap SHHQ ,to seeAoIdLu~ 'm, uauJeJ!nbeJ e~.e),s pus leJepa~, u!ePao/~.s!~.es o~, Jep~o u! suoi~.n]!~,su! 6u!pual ~!eqi pus sat..u oq J.o s.~eseqa.~nd o,t Ase~..~noo e se s!q,t seop SH HQ aql 'eHSelV ,to e~.e~.S aq), u! peJe].s!Oa.~ .~aeu!6ue leUO!SSa,toJd ~.uapuadepu! ue ,~q e^oq~ ~; qdeJl~e.md u! ua^!6 suo!~.m, uaseJd@.~ aq~. uodn AlUO paseq le^oJddv A,tpoq,tnv q~.l~aH senss! (SHHQ/ seo!^JaS uet.unH pus q,tleaFl ,to ~.ueuu~JedeQ eSe.~oqouv NOI/Iq¥O leUO!l!puoo le^oJd%euo!]!puoo ,to SLLJJa/ pa^oJddes!(] ~ pe^oJddv /~q SLUOO~paq ~/?~. ~'~R~4/ JO,t pa^oJddv 'l~AOl:ldd¥ SHHa '9 MU. C .AUTY OF A.C.ORAGE ~I~T~L ~O~tO~ CHECKLIST- FEBRUARY 1984 WELL DATA Legal Description: Well Classification Well Log Present (Y/N) Total Depth ~ '7~,O ° Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Cased to '+ ~ © If A, B, C, D.E.C. Approved (Y/N) Date ComPleted i ~ '1 '?_-. Yield Depth of Grouting Pump Set At ~- / Sanitary Seal on Casing (Y/N) ~: Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lo't7~- 7~' _¢ '/LZ-*1 ~./2/.'~'~On Adjoining Lots /w~,~.- Z To Nearest Edge of Absorption Field on Lot /cc,., .Pc ; On Adjoining Lots To Nearest Public Sewer Line `-/- / O C~ * To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments /~/_. c) ~ SEPTIC/HOLDING TANK DATA -t- / cD 0 / To Nearest Sewer Service Line on Lot Y- -~- C) / d~.. ~,.~-, ; Date /:- Z-4; --27 ~ -~5 -T ~/~u~"~ /'- ~ ~ -- ~7 //,.2 Date Installed Standpipes (Y/N) Y"- Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /%} l'°f- Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line ~ Z,, 0 To Water Main/Service Line Course 'H /g,O" g? -- ,7/ Size /~' :~-0~:~ No, of Compartments Air-tight Caps (Y/N) ~/ Foundation Cleanout (Y/N) Date Last Pumped /- Z.'Z. -- ~'7 ~ ' ' /~'~! ' for Temporary Holding Tank Permit (Y/N) /1J To Building Foundation 2LO' To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 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 ,'~'~:3~'~;'/..2/-I¢ ~'~ Separation Distance frorg. Absorption Field: To Water-Supply Well ;)J~/~:25 To Building Foundation Lot ,'~,/ /Jr To Water Main/Service Line ..F- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Ve~bicle Storage Area Comments '"?¢ ///~',.,~/-,/.-~/~J¢// Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test y ,- / To Property Line "¢'" / ~ To Existing or Abandoned System on ; On Adjoining Lots ,-/-/0 0 t To Cutbank (if present) /L2/~- D. LIFT STATION ~ Dimensions ...-- · Size in Gallons ~-~,.__ Manhole/Access (Y/N) "Pump On" Level at '"~"~_ "Pump Off" Level at ~..~'"'"'~'"~ High Water Alarm Level at -'~'"~--.. ...Verft"~(Y/N"~'~ Tested for ' .~.,..~_~~es during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that J ha~e c~qe, cked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Receipt No. Date of Payment // ~¢/~ Amount: $ l ~,,~ ~ Page 2 of 2 72-026 (11184) ~ . , ,.~: ~ ~ ANCHORAGE ~ DEPARTNEN7 OF~-'~,~,.~_-"u. Al'ID ENVIRONHENTA, ?ROTECTIO?,', o2q L Street, Anchoracro, Alaska 99501 264-4720 Date Received: December 1, 1977 i~ ]_: Time __2_:~3_.0_~_._.m~_. Da ke A2_,_5~17_7__~o.~ay In sp Pratt Dau~ 12-6-77 Tuesday Date Rh,QUr, oi FOR APPROVAL OF iNDIVIDUAL SEWER AND WATER FACILITIES 1 Lending Inst:Ltution Request: Alaska Statebank % Shirley Mailing Address: 310 East Northern Lights Blvd. Phone: Property Owner: Harvey M. Prickett Mailing Address: Star Route A Box 95A 99507 Phone: 344-5773 3. Legal Descr_~.p ~ ~.on. Single Family Residence: (x) Multiple Family ResJ_dence: ( ) Lot 32 Lakewood Hills Subdivision Number of Bedrooms: Number of Bedrooms: Well System: Permit {! Construction · ' ~ ,~' well (X! Community/Public System ( ) Ind IV l (_Lhd J_ , .- Depth of Well 120' Well Log on File ( ) Bactermd ~ Analysis 6. Sewage Disposal System: On-site System (x) '7. ~.~oe.~m2.~-'t~ i~" Installed 1972 Absoxption Area Soils Ra'te Distances: Well to Septic Tank to Sewer T {· Public Utility ( ) Installer Material to Absorption Area Nearest Lot line Absorption Area to Nearest I,oh Line Page ?we ~ Department of Health and Environme.n%ai Prohectien ~ ~or Apprevai o~ Individual Sewer L~al Desc~:iptJon: Lot 32 Lakewood Hills Subdivision Disappreved: Da~e: Department Works~eet: ~.~-~,. - o ~,: oao ~ II~P~ I~NOIIVHStlN[ ltOJ ION I Z6I '~dv (ep:~ ~eq~o e~S) --n]01101Jd ~IgVItIA03 ]3N¥~IflSNI ON 008£ u~o=l Sd .......................... (pe~mbei set o~lxe) 183^l~3Q ~8 ............ llUO easssdppe ol [Ja^qap ql!~ PS9 ............ AlUO aessa~ppe el Ale^ lap ql!~ ~S! ........... pa~aA!lap alep p~e mona ol sA~qS -- S]]~ 1VNOIIIOOV 80~ S]OIAa]S 1VNOIl~dO (e~e},sod snld) ~}O~:~llV~ O~]I:IIJ. UB3 ~0J P ~ ~±_ mUNICIPALITY OF ANCHORAGE .. = 825 L Street, Anchorage, Alaska 99501f--~- ...... ~ ..... ~quest for Approval of Individual Sewer and Water .Fa~iliti~es . 0wn r: Mailing Address: 3~ ~~/ /~.~~Phone: 2. Name of Buyer: ____ ~ /~ Mailing Address: f/~ ~~ ~- Phone: 3. Lending Institution: ~~~ ~_K~ ~ ~ ~/~/ Mailing Address: Phone: 4. Real q or/Agent: ~~ ~~~~~~' Mailing Address: ~ ~/~ ~~' Phone: 5.Legal Description: ~ ~ ~ ~ ~~~ ~ Street mocation:~__~ ~ ~ ~ ~ ~~ Multiple Family Residence: ( ) Number of Bedrooms: Water Supply: *Individual Well If Individual Well, well depth _/~0 If Community System, name of system Public/Community System ( 8. Sewage Disposal System: *~n-site System ~) Public System ( If On-site System, date of installation: /~ . *NOTE: A well log is required on ALL wells drilled since 6/75. ** If on-site sewer system is over two(2) years old, an adequacy .test is required by this department. A fee of $25.00 must accompany each request before processing can be initiated. 3/77 GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received ~;/~ ~.,/7 ~ Time of Inspection 9,'00 f?'/~?' Approval requested by: Mailing Address: 2. Property Owner: 4. 5. 6. Mailing Address: Legal Description: Location: Phone: Type of facility to be inspected Well Data: A. Type-.. ~-'/i.".. ~ / C. Construction 7. Sewage Disposal System: A. Installed t~:/ C. Septic Tank: 1. Size D. Seepage Pit: ?> B. Installer ~_.yZ~.'~,~ /~ .~-o 2. Manufacturer 1. Absorption Area /~/ 9~--' 2. Material E. Disposal Field: Total length of lines e Distances: A. Well to: Septic tank (f?~ , Absorption area -- Sewer Lines , Nearest lot line ,.~ :~---', Other contamination B. Foundation to septic tank ,~"~ , Absorption area C. Absorption area to nearest lot line EQ-034 (1/74) Page 1 of two pages 'Pa~e 2 of two pages - Re~est for Approval of Individual Se?Jer & Water Facilities Legal Description Approval Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM f I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date