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Home My WebLink AboutSOUTHPARK #2 BLK 2 LT 14'~--~, ' ?'-% 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 MAILING ADDRESS LOCATION NO. OF BESOMS ~'4 Manufacturer~,~,~ %~/~ ,, . Materials~% No. of com%ents ~ ~ Liq. capacity Cn ~llo&s ~ Inside length Width Liquid depth Well Foundat ~ ~ ~ Top of tile to finish gr de Material be~ath tiJ Total effective absorption area ~ ~ Type of crib Crib diamet~p/ Crib depth Total effective absorption area ~ W¢li Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO, ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER RATrNG ~( ~ ~ % 72-013 (Rev..3/78) DEPEIRTHENT OF' HERLTH RND EN'v'IRONMENTRL PROTECTION 8R5 L STREET., BNCHORBGE., FIK 9950i 264-4?20 _ _-4--.:,, ]( "TE S; E.--% ~-.,.~ E F..: F'E E:;;:~"] Z T F'EF:H I T NO: [}RTE I-",:,UE[ . E:40"L75 04,.."::L2/84 FIF'F'L i Z FIN:-' FiB, DRESS: CONTFIE:T F'HOI'.,IE: LRNDMF:iRK-'¢EIqTURE I...TD P 0 BO::-;: ±:1.':L654 RN[.]HORRGE, RI'< 995±1 ]i:45-4807 '1. E3RL [.Ez,_E. iF : LCT _,I~.E. 1M,, !..,L [. I,J_._ffd .... '::;I IE:F':,I ',,,'I'::'[nN: SOUTH PRRK ~I~;2 LOT: ..,E.... F.[L~ 2: TOHNSHIP · ~iN ~.PINaE ~:H ;::Zi~t00 ':. bL.L F'T'. ZIP fl ..~ Ez, · 4 I...ISTF[', E, ELuI..! FIRE THE uFTILfl,I=, PI,HILME, LE '¥O Y]U IN DESIGNING '.r'l~ltlR _,EFTIL. '--"": .... ':- - : '-' " " - .~,~ _,] Eft. L. HCIt..L.,E IHE uFTIuN ]HRI E:--'= '._,'2' ''"TUI_I~.' '-z, tTE. -DEPTI-! TO ,PIPE: [80TTOM (E'T.) GRFP,,'EL B, EPTH '::FT. ) TOTFIL. DEPTH ,::FT. ::, GRFI',,,'EL:!,.IIDTFI (FT. ::, GRFP?E!... LENGTH (E-F.) GRR',,,'EL ',,,'OLUHE (CU. "PDS. ::, TRNK SIZE <GFI[_S) SOIb. REITINO (SI]:L fUT. ,."E:R) :+::+: UE.I":I E.L LENGTF! ]::' ?h [:'"F. *>t.: TFINI.( MUST Hhl- 'c.F [:IT RUfI..':' <NOT E--,LEE["" ..... If',It~ '7~ F"F. ERCH) Z:OMPR[['TMENTS' i CERTIFY TFIRT: t.. I ElM FBI"IlLIRR P.tlTFI THE REQUIREMENTS FOR ON-SITE SEI.qERS RND HELLS RS SET FORTH BY THE MUNIC!PRL. I-FY OF FINCHORRGE (i"10R) RN[:, I'HE: STFITE OF FILFISKFI. 2. I HILL. Ii",[STFILL THE SYSTEM IN RCCORDRNCE I.,[ITH FILL MOB CODES FIND REGULRTIONS, FINE:, iN COMPLIFINCE NITH THE DESIGN CRITERIR OF THIS F'ERMIT. _'2:.I HILL RDHERE TO RL.L ['IOE~ RND STRTE. OF RLRSKR RE64UIREHENTS FOR THE SET BRCK DISTBNCES F'[4'.OH F:Ii'.4Y EXISTING HELL .... I.,.!FISTEHIaTER [:,ISPOSFIL SYSTEM OR PUBLIC SEHERFiGE SYSTEH ON THIS OR FINY' RDJFICEMT OR NERRBY LOT. 4. i LINDERSTRND TFIRT THIS PERMIT IS YR[_ID [:'OR F':l MR',:',;IMUH OF 4 BEDRCIOHS FIN[:, RNY ENLRRGEMENT HILL REQUIRE FIN FID[:,ITIONf~L PERI"II]"; IF El LIFT STRTION IS INSTtaLL.ED IN RI'.,! RRER COYERED BY MOB BUILDING CODES., THEN ,::::L::, RN ELEC'TRICRL E'ERi'"II-F FIND INSF'ECTION HLIST BE OBTRINE[:'.~ (2) A2;-E:UILTS i.4ILL NOT BE: RPPROYED I-4ITHOUT ¢:]N. ELEC:TRIClaL INSPECTION REF'ORT.~ RN[:." (:Z:) ]'HE ELECTRICI:-~L 'HORK i'iLiST BE [:,ONE B"r' R LICENSE[:, EL. ECTRICIFIN. .., I .~r,lE[ . . [:,FITE: RF'PL 112RNT: LI._~IN[:,HEIE. K--. ,~, ENT J[i'F:Z LTl, B, FITE: ~., , ... ° " '; /~' ~ ~ - POO,_.,hl 6-650 ~ ~V~L tu~ l['~ ' t~ ~' * r~ J~ ' ~: ~t ~~ ANCHORAGE, ALASKA 99502 0650 - ~ ~" ' ,,/ (907) 264-4111 Permit ,, 840;1-75 ,j~~ O~ TO: Permit Applicant SUBJECT: Lot 14 Block 2 Southpark Subdivision 92 A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as-built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Keith E. Bandt, SupeYvisor Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 I I$00 C,~GE RD. ANCHORA~£ ~ AK. (907) 345-~00~ SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 4- 5- 6- 7 8 9 10 SLOPE 11 12 13 14 15 16 17 18 19 THOM A. IE~ .~ CE - 6793 SOILS LOG [] PERCOLATION TEST SITE PLAN WAS GROUND WATER ~...~ ~ ~ ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? ,// Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN FT AND (minutes/inch) -- FT COMMENTS pER FORM E D By: '~'-~{C,¥~ ~'~ ~(~(~'~ £,~"~ CERTIFIED BY: DATE: ~ 'SOILS LOG ANCNORA~m~ ~K. ~9§16 ~ . (90~) 3~-~ ~ PERCOLATION TEST SOILS LOG -- PERCOLATION TEST PERFORMEO FOR: SLOPE LEGAL OESCRIPTION: ~'~ 1 2 3 4 5 7 DATE PERFORMED: SITE PLAN 10 11 12 13 14 15 16 17 18 19 20 COMMENTS WAS GROUND WATER ~:) I~ ENCOUNTERED? O P E IF YES, AT WHAT / DEPTH? Gross Net Oepth to Net Reading Oate Time Time Water Drop , PERCOLATION RATE TEST RUN BETWEEN .~- Y~, ~'-'f/'['r¢ .{minutes/inch) FT AND ~ FT PERFORMED BY: CERTIFIED BY: DATE:. ~ SOILS LOG 1600 ~NCHORA~E , AK. (907) ~5--71~ ~ PERCOLATION TEST SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 13- 14- 15- 16- 17- 18- 19- 20- SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop 4 " io;/o PER CO LATiON RATE s~.~ "~ ~'~------) (minutes/inch) TEST R.N ~ETWEEN ~ FT AND ~ ,PT COMMENTS PERFORMEDBY:~(-~/V.%. ~.~(.~1¢)-~. CERTIFIEDBY: DATE: MUNICIPALITY OF ANCHORAGE DEFARTMENT OF HEALTH AND ENVIROr'~I~,',ENTAL PROTECTION 825 g Street, Anchorage, Alaska 99501 254~720' SOILS LOG - PERCOLATION TEST ~ ~ / SLOPE ~ITE PLAN - DEPTH~ ' I I -I ¢ I I~.oo z e I/ ~ .',~ .~J ~-~, I ~ flao I I ~ ot I I /.~ .,,' "L~-~F 4~1 I S I I' ¢3/ I .~ I/.U¢ ~~-~-~:- · ~ · . 'l~7;;;~k~.~.· .. ~s~' ~. ~- ~", ~ ;~' COMMEN1 PERFORME~BY: ~~ ,_CERTIFIED BY: ~'. ~, '- ,- .~.-'~.~ [~,~ ::~ DEPARTMENT OF HEALTH & HUMAN SERVICES_. *, . P.O. Box 196650 Anchorage Alaska. 99519-6650 : '~ ' '~ - ', ~.' CERTIFICATE OF HEALTH AUTHORITY --. ~.: ;:, i~ '~ ~ ~ APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. ~ 0~0-- o~-- ~ HAAg 1. GENERAL INFORMATION Location (site address or directions) ~ F ~ I ~o~ ~ '.{?i!i', Pr0Pe~ylowner ~v~ /)~o~c~5' Day phone (~--~ - '7 / ?r~' '" Mailing address ~0-~1 ~t.,_.~.z.t '~o~..g~ ~(-~d~ ~~v~--- Lending' ~gency "'~"'~c~-~v~"~ ~-~ ¢~- ~ ~ Day phone Mailing address Address ~(~ z.;-~ ~ ,.oL~?o t..,~ = Unless otherwise requested, HAA will be held for pickup. // NUMBER OF BEDROOMS: L.// TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system._- 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site C0mmunit~' on-site 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 STATEMENT OF INSPECTION By ENGINEER*~' As certified by my seal affixed hereto and as of the validation date shown below, I verity that my 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 verity 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 r,egplations in effect on the date of this inspection. Name of Firm / ~ ~-~ Address ~ Engineers signature Phone ¢~'77-~'~//~' DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Munioii~slity of A~ nchorage 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 tosatisfy 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 errors or omissions in the professional enginesr's work, Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: Lc,-~-IL}~I~ "2. L.C,,~,[,-LG'~,~.x~t47- ParcelI,D. O,20~O.~,~--~O A. Well Data Well type F~/-%" Log present (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number [~/'~¢1 D, ~"/¢- J .~ ~/7~~- Date completed Driller Total depth Sanitary seal (Y/N) Cased to Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot g.p.m. AT INSPECTION ; On adjacent lots g.p.m. Z Absorption field on lot ; On adjacent lots Publio sewer main Public sewer manhole/cleanout Sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B, SEPTIC/HOLDING TANK DATA Date installed ¢°,/'~7,/~ '7/ Cleanouts (Y/N) Tank size /~ ~ ¢.~ Compartments High water alarm (Y/N) Date of pumping Foundation cleanout (Y/N) "/ Depression (Y/N) h-/,/",~ Alarm tested (Y/N) J"¢'///"'~- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /"7//~~, On adjacent lots /'"¢,~-~- Foundation To properly line .> / ~ Absorption field ~:, Water main/service line Surface water/drainage /'"//C) 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level 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 ~ -~ 7-~ ~ Length c.~ ~, Width Soil rating (GPD/FF) ~-'~(-~ System type / ,~.-/~'~',/_,Z Gravel thickness ?,~ 7~.~ Total depth /~ f Total absorption area /~ ?,~. Cleanout present (Y/N) ~',~ Date of adequacy test Z~'/'~/'~ V/ Results (pass/fail) '~ for Water level in ~.bsorption field before test ~ ~ Peroxide treatment (past 12 months) (Y/N) ~/ /& After test If yes, give date Depression over field (Y/N) ~'"/ ~-,.--'/ Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ' /','~- To building foundation On adjacent lots Surface water Cur[din drain On adjacent lots ¢"~/J~- Property line To existing or abandoned system on lot Cutbank ~%~ ,-~ ~ Water main/service line Driveway, parking/vehicle storage area ¢-~('.} E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines in effect oq fhe date of this inspection. HAA Fee $ ~' Date of Payment Receipt Number ~)---'~-. ~¢~'-.~,~ 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEAL.TH 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) Lot 14 Block 2 Southpark #2 Subdivision 7/8/85 Location(addressordirections) Southpark Bluff Drive (b) Applicant Name Landmark-Venture Telephone: Home Business 345-4807 Applicant Address P.O. Box 11-1654 Anchorage, Alaska 9951] (c) Applicant is (check one): Lending Institution []; Owner/builder [~; Bpyer []; Other [] (explain); (d) Lending Institution Address (e) (f) __Telephone Real Estate Company and Agent Address Telephone Mailthe HAA to thefollowing address: TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number of Bedrooms Four (4) Other WATER SUPPLV 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. 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. Page 1 of 2 72-025 (11/84) 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, end regulations in effect on the date of this inspection. Name of Firm __ Telephone Address Date Enginee~ Seal This office has received written confirmation from the Engineer (Thom Fischer) that the conditions of June 1985 have been met. Therefore, this property meets MOA requirements. DHEP APPROVAL · ' Approved f~)r ~'¢¢~,,/~:.-('~ )bedrooms by Approved _ "~ Disapproved Ter~ns of Conditional~Approval /'/ I "~\\' ~-~.~C~.?'~/~ Date Conditional 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 inspeclions 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 P.O. BOX 3-4016' ANCHORAGE, ALASKA' 99501d MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT. OF BI~ALTH AND ENVIRON~fENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1o General Information Application Date (a)_Legal~- ~ ~-----~--~--~Descripti°n ( in_.c~ude lp~ block,....~-~5 ~"~ +~~'z~'subdivisi°n' section,~ip,~''~t°wnship'l~- ~range) Location (address or directions) (b) Applicants Name ~f~'~O ~_j~M~¢i_ --~fF~'-a~-z~-Teleph°ne - Home Business Applicants ~dress~ ~ ~ I ~ /~- ..-- ~+~g~ (c) Applicant is (check one) Lending Institution ~ ; ~er/builder~ ; Buyer ~ ; Other ~ (explain); ~ (d) Lending ~iY6ii~h- .... ~ ~~hone Address ~ (e)Real Estate Co~ & Agent ~~ Address Type of Residence Single-Family~~Multi-Family~--~ Number of Bedrooms ~ Other (describe) Water Supply~ Individual Well ~-] Community.~ Public ~ Note: If community well system, must have v~itten 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 1 of 2] o En__~gineering 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 disposa% system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm Telephone (ENGINEER SEAL) DHEP Approval Approved for .~'~Z~j bedrooms Approved Disappro~ved Conditional T~rms of Conditip~nal Approval ~Ot~lJc~l~~ ~.~'~-°xr~'t-'~ CAUTION THE liDiqICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESEb~- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY ~N 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 REQUIRE= MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF kNCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SE.~L) RR4/ej/D18 [Page 2 of 2] 7 -19-84 ae MUNICIPALITY OF kNCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 ~.~LL DATA EN¥1RONMENL',L i;., ;L,2; , j RECEIV .U T.egat DescriDCion: [,,'-~'l-- Ic'~ Lf:~(. ~ If A, B, c~ C, D.E.C. Approved(Y/N) Date Completed Depth of Set At Well Classification Well Log P~esen~~ Total Depth Ca~d~ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances Scm Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field/~n Lot To Nearest Public Sewer Line C leancut/Manhole Water Sample Collected B~//// Water Sample Test Pesu~s C~,~ents To Nearest ; Seal on Casing (Y/N) Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Service Line on Lot B. SEPTIC/HOLDING TANK DATA Date Installed ~A ~ / ~- Size i~Z> No. of Cc~3a~tments Standpipes (Y/N).~ air-t~ght Caps (Y/N) y~ Foundation Cleanout (Y~) ~ession eve= Ta~ (Y~) Nu ~te ~st P~d ~ [~ P~ing~intenan~ ~n~a~ ~ File (Y~)~/~ ; for Holding Ta~ High-Wate~ ~a~ (Y~) ~A ~ra~y Holdi~ Tank ~t (Y~) ~p~ation Distan~s ~ ~ptic~olding Ta~: To Water-Supply ~11 ~ i~.+ TO ~ilding F~ndation To ~rty Li~ ~ f~ To Dis~sal Field ~ ~ To ~ter Main/Se=vi~ Li~ '~ ~ To' S~, Pond, ~e, ~ Major ~aina~ [Page 1 of 2] ABSORPTION FIELD DATA Soils Rating in Absorption St2ata Date Installed ~ ~q- I ~ 5- width of Field ~ ~' Type of System Design ~.14- _ Square Feet of Absorption A~ea iO c/ ~_ Depression ove~ Field (Y/N) ~o · Date of Last Adequacy Test Results of Last Adequacy Test ~'~ (6 Separation Distanoe f~om Absorption Field: To %%ater-Supply Well ~.~qi> ,~- To P~operty Line ~ f Length of Field ~---~ ' Depth of Field I~-~ Gravel Bed Thickness I I ~ /~ Standpipes Present (Y/N) ~ To Building Foundation ~ / Lot ~ (~ ; On Adjoining Lots ~23 'ff--' TO Water Main/Se=vice Line I~ ~ To Cutbank(if present) To Stream/Pond/Lake/o~ Major D~ainage Course ~4/Pr To D~iveway, Parking Area, o~ Vehicle Storage Area ~ / To Existing or Abandoned System (ha Coma~nts D. LI~ STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Leve/1/at / Tested fo~ Coma~ntsElect~ical Code~/¥/N) Pump ~f Level at ** Check Permitted Bedroom Rating Against HAA Bequest I oertify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this ins~ction. Signed ~ -~s(~~--~-- Date Cun%~any ~---~(_~CJF.~ ¢~3 MOA No. KB1/d5/s [Page 2 of 2] BILL SH£FFI£LD, GOV£RNOR Telephone: (007) Address: ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 'ANCHORAGE, ALASKA 99501 274-2533 To Whom it May Concern: According to records on file in this office the ~ Water Regulations Water System is in compliance-with the State Drinking Sincerely,