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HomeMy WebLinkAboutSOUTHPARK #2 BLK 3 LT 14 Municipality of Anchorage Page i of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SW910221 PID Number: 02005261 Name: Wastewater System: ~New [] Upgrade Mr. Robert Foreman Address: ABSORPTION FIELD 1055 Horizo~ Dr. Ventura, CA 93003 Phone:907_562_1500 No. of;edrooms: ~peep Trench [] Shallow Trench [] Bed [] Mound [] Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: · 6 GPD/Sq. Ft. ~ Lot: Brock: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe 14 3 South~ark Add ~2 3.5 Ft. 8~ Ft. Township: I Range: Section: Fifl added above original grade: Gravel length: 11NI 3W 3 ~ ~ ' Ft. 47 Ft. wegLi~xist [] New [] Upgrade Graveldepth: Numberoflines: IDistancebeiweenlines: C'nmmunihr ' "9 Ft. ], N/A Ft. Classiflcat[o~ (Private, A,B,(~): Total Depth: Cased TO: Total absorption area: Pipe material: Ft. Ft. 750 SO. Ft. ASTH 3034 Driller: Date Drilled: StaticWater Level: Installer: Date installed: Ft. Carl's Excavatinq 8/6/91 Yie,d: GPM IPump Set at: Ft. ICasing Height Ab°ye Gr0und:Ft. TANK SEPARATION DISTANCES ~eptic [] Holding [] S.T.E.P. TO Septic Absorption Lift Holding ~ubli¢/Privat6 Manufacturer: Capacity in gallons: From Tank Field Station Tank ]ewerLines ARch Tank i, 000 Material: Number of Compartments: Well CommuNity Water ystem ,qt, pp] Se,face LIFT STATION Water None ====== ====== =====: --==== Lot Size in gallons: I Manufacturer: Line 50 ' 20 ' None ====== ===== None I F°undati°n's' 22' None ........... "Pump on"level at: ["Pump off"level at: [ High water alarm at: Curtain = Sump Make & Model Electrical Inspections per[ormed by: Drain None ===== ====== ===== ===== Remarks: aanl-,i c ,'?~rom 8/10/84 BENCH MARK Location and Description: installation was relocated for this ~g~ ~ O'{c draln~i~ld r~r~l a c,l~men t. Condition was qood. [Assumed Elevation,~Oi ~, ENG NEEF~S SEAL .-~%'.-'" , A "...'C~'~, Inspeetion$ performefl by: aountain Enqineer in[~l, te$:2ndlst. 8/6/918/6/91 ;,~~'- [ .-~ %° MARK W. PEARSON' ~a~/,% CE-7760 Department of Health .arid Hwn~ln Serv. i.e'~s approval ,, ~'... ...' ate ~ '%,. Reviewed and approved by: -v --- ,.-~ ...-- .- : 72-013 (1/91) MOA 25 Permit No. SW910221 Page 2 of /~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal[])escription: Southpark Addition ~2, Lot 14, Blk3 PIDNo.: 02005261 SEAL HARK W. PEARSON CE-7760 72-013 A (2/91) MOA 25 Permit No. ~J ~ I 0 ~.. ~ I Page Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report PID No' ~ ~.0(2 ~'~'(~ I 72-013 A (2/91) MOA 25 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW910221 DESIGN ENGINEER:MOUNTAIN ENGINEERING OWNER NAME:FOREMAN ROBERT A & OWNER ADDRESS:1055 HORIZON DRIVE VENTURA, CALIF. 93003 DATE ISSUED: 8/01/91 EXPIRATION DATE: 8/01/92 PARCEL ID:02005261 LEGAL DESCRIPTION: SOUTHPARK ADDN 2 BLK 3 LT lg 4 LOT SIZE: 25690 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST 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 (ISAACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: SSUE ~_o~n~.o 0 o %0 ~ o~ 0 o © N12~, -nB 220.60 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: ~'~ I L~ ~('~2(~¢-~ "'~/50 Township, Range, Section; SLOPE SITE PLAN 1 2 3- WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water Afte~r r/~_/',l~.~ Monitoring? Nv Y - Date: 5- 6- 7 8 9 10 12 13 14 15 18- 19- 20- T~[ 7t o ~ PERCOLATION RATE ~,O (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN '~ FT AND Gross Net Depth to Net Reading Date Time Time Water Drop .., ; b% ,¢ I [~/~/'k ?Ok'~/',~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCEWJTHALLSYATEANDMUNICIPALGOIDELINESINEFFECTONTHISOATE. DATE: '-~/'~I~) 72-008 (Rev. 4/85) 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 ~]AI LING ADDRESS LEGAL D'ESCR [PTI~ ' ' LOCATION DISTANCE TO: Absorption are.~ Manufacturer Inside length Width IF HOMEMADE: Well Dwelling DISTANCE TO: Manufacturer Material Nearest lot line £,~ DISTANCE TO: No. of lines Trench w~( hit inches Top of tile to finish grade ~ Length Width Depth PHONE '&46-~T&, 17-- ,t~NEW [] UPGRADE NO. OF BEDROOMS No. of compart~ts PERMIT NO. Liquid capacity in gallons PERMIT i~i.4 _ Distance between Lines Tota, effective PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well 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 PIPE MATERIALS ~--~-- i SOl L TEST RATING INSTALLER REMARK8 DATE LEGAL £:,EF'RRTMENT OF HEFILTH RND EN',/IRONMENTRL FRuTEL. TI_H ,:,~-:.._ L ~TREET., RNC:HORFIGE., FII< '9'95E~± F'EF.:H I T NO: [:,RTE T'::'-- ~'r-. E:40094 k.1 _':. ,"'.=: ~ ,." o4 rF-I _.HI'.I F!D E:'RE SLE,: CONTFtCT PHONE: L. EGRL DESCRIF': S;UEOF,,,'ISIOiq: SOUTH PFIRK fi2 LOT: :24- )~SECTION: 3 TOHNSHIP: :/iN RRNGE: ]:H LOT SIZE: 2569E~ ,::SgL FT. OR RCRES) MRX BEI:,RO071S: 2: BLOCK LISTED BELOH FIRE THE OPTIONS RVFIILRBLE TO '¢OU IN DESIGNING '?'OLIR SEPTIC: S'.?STEI',I. CHOOSE THE OPTION TFIRT BEST F:tTS YOUR SITE. DEF'TH TO PIPE BOTTOM <FF. > /4. 0 ~ 4. E~ 4. GRFf,/EL DEPTH ,::FT. ::, ~ L.-t 5 _--:'.. 5 TOTFIL [:,EPTH <FT. ::, 4. 5 7. 5 GRFIVEL HIE:,TH <FT. ',' ±7. ~9 5. GRFIVEL LENGTH <FT. ', 34. E~ 4:L. Fj -. ~,-~ , ' - .~:Et. ~F~I-t EL VOLUHE ,::CU. ¥[;,S. ', ;~±. 4. -. ,-': "~-' :L., E~C40. E~ :+':+' :IL., C4EIEL TFiNK ..., I ,,_E ,:: Gl:ILS ) _,uIL RFITING <Sg!. FT. ,. E,F .... :2,~.- :+,:+, 'FFfl'-~k: MLIST HFf¥'E FiT LEFISI: THO COMPFtF<Tf'IEN'FS I CERTIFY THFIT: I Ri'"i FRHILiFIR HITN ]"HE REQUIREMENTS FOR ON-SITE SEWERS FiND HELLS RS SET FORTH 'B"¢ THE HUNICIF'FILIT'¢ OF RNCNORRGE (i'qOR) RND THE STRTE OF RLFISKB. 2. I HIL. L. INSTFtLL TNE S¥S~f'EM IN BCCORDRNCE HITH RLL HOB CODES FIND REGULRTIONS, FIN[:, iN COMPL. IFINCE HI;TH THE DESIGN CRITEF.:IR OF THIS PERI"IIT. "4:. I HILL 81]:,HERE TO PILL. MOB RND STFFrE OF FtLRSKR REE!OIREMENTS FOR THE SET BRCK [)ISTRNE:E:E; FROM FINS.' EHISTING HELl .... HRSTEHFITER DISPOSFIL S'¢:5'TEH OF.: PUBLIC SEHERFtGE :.E,'¢STEN ON "[NIS (]iR BN"r' RDJFtCENT OR NEFIRB"r' LOT. 4. I U!",!B, ERSi'FIND ]"['-IR"l" THIS PERi'"II"F tS VRLID FOR F~ MRXIHLif'I,OF 2 BEDROOMS RN[:' RN"r' ENLFIRGEHENT P.IILL RE6!UIRE RN BD[:,ITIONRL PEF:i"IIT. L~_F'T STRTION IS INSTFILLED IN FIN RFi:E:R COVERED B'¢ MOB BUILDING COB'ES., '-'.':2) RN ELECTR!CRL PERHIT FIND INSPECTION I"IUST BE OBTFtINEDs (;2) RS-BUII...T~ NOT BE RPPROVED HITFIOUT RN ELECTRICFtL INSPECTION REPORT; RND (3) THE F.IOF.:K NUST BE DONE BY R L. ICENL-]ED EL. ECTRICIRN. ROBERT FOREHF%,I CONSTRUCTION iF R THEN I.,.I I L L ELECTRiCI~L S I GNEE:, H~ FLIL. HI,I F. ISSUED E:'¢ & 'ENGINEERS, INC. 7125 OLD SEWARD HIGHWAY ANCHORAGE, ALASKA 99502 (907) 349.6561 SOIL LOG PERCOLATION TEST SOIL LOG PERCOLArION TEST BEDROOMS ~OR .D*BER:` .._40 I Z:/- 9 0--d~),5 PIE;z~'' -4" O~'&.,~l¢-.,~_ p,1'~. SLOPE SITE PLAN 11 - ~1 ~ WAS GROUND WATER S ENCOUNTERED? ~ L 12- ~ E IF YES, AT WHAT DEPTH? W E ] I Gross Net Depth to Net Reading Date Time Time Water Drop DEPTH PERCOLATION RATE ~/1 ,_~t~J ~: L (minules/inch) (FEET) COMMENTS PERFORMEO BY: ~ ~)~N.NI~.~ -1~-~'~. CERTIFIED BY: ....... OATE: 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 02005261 HAA# 1. GENERAL INFORMATION Complete legal description Southpark AddibioD %2, Block 3, Lot 14 Location (site address or directions) Southpark Bluff Drive Property owner Mailing address Lending agency Mailing address Mr. Robert Foreman 1055 Horizon Drive Day phone 562-1500 · Ve~t-ra C~ 930nR Day phone Agent Darlene Ellison Address 3000 A nh~-,=,=~-; An~'hn~'nge; A~ 99503 Unless otherwise requested, HAA will be held for pickup· NUMBER OF BEDROOMS: 3 ~ TYPE OF WATER SUPPLY: Individual well Community well X Public ~vater NOTE: Dayphone 562-?653 If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: x individual on-site Holding tank Community on-site 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 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 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 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 Mounta]n E~Lgineer ing Phone 562-1500 Address 3868 ~cle, Anchorage, AK 99508 Engineer's signature ~,.~__..~/-~/~._ . ' Date 8/6/9 1 6., DHHS SIGNATURE /~ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: . . . 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 errors or omissions in the professional engineer's work. 72~}25 (Rev. 1/91) Back MOA#21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A, WELL DATA Well type A Log present (Y/N) Total depth Lot 14 Parcel I.D. 02005261 If A, B, or C, attach ADEC letter. N/A Date completed Cased to ADEC water system number Driller Casing height 213475 Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Wires properly protected (Y/N) AT INSPECTION Z Septic/holding tank on lot ; On adjacent lots Absorption field on lot ; On adjacent lots Public sewer main Public sewer manhole/cleanout Public sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed 8/6/91 Cleanouts (Y/N) ¥ High water alarm (Y/N) Nitrate Other bacteria Collected by: Tanksize 1,000 gallons Compartments 2 Foundation cleanout (Y/N) ¥ Depression (Y/N) N/A Alarm tested (Y/N) N/A N Date of pumping New system, installed 8/6/91, permit ~SW910221 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot None To property line 50 ' Surface water/drainage On adjacent lots None Foundation 8 ' Absorption field 22 ' Water main/service line No~ 50' 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at High water alarm level Meets MOA electrical codes (Y/N) Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed 8/6/91 Soil rating Length 47' Width 3.5' Gravel thickness 8' Total absorption area 750 FT2 Cleanouts present (Y/N) Depression over field (Y/N) N Date of adequacy test Results (pass/fail) New installation 8/6/91, for Peroxide treatment (past 12 months) (Y/N) N · 6 GPD/SFSystem/ type Trench Total depth 11 ' Y New Installation by Carl's Excavating bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot None To building foundation 20 ' Onadjacentlots GT 100' Surface water None Curtain drain None On adjacent lots None Propertyline 20 ' 17' · To existing or abandoned system on lot Cutbank None Water main/service line 60 ' 80' 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. Signature ~.~'.- Engineer's Name Mar]( Pearson ,,,-,,,~ .... Date 8/6/91 MARK W. PEARSON CE-7760 HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number ANCHORAGE DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 August7,1991 WALTER J. HICKEL, GOVERNOR 563-6775 FOR: Mark Pearson PWSID 213475. My review of the records on file in this office reveals that the South Park Subdivision Phase 11 Class A Public Water System, is in compliance with the provisions of 18 AAC 80.060, State of Alaska Drinking Water Regulations. Keven K. Kleweno Lead Engineer 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 Date ' .~ c--- Application -7//~'~/~'.~ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name "'~-~A~.~.E¢-tT- /;~'Tc~t'~%e~;"p~: Home ~'~-<~'~--~7~t ~usiness Applicant Address _%~... C..__bt ,~-~..'h~'~. I [ ~- / "7 ? [,,~r~'~('-(-4-~'cr~:: ~.~'- (c) Applicant is (check one): Lending Institution []; Owner/build.dyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family,~ Multi-Family [] Number of Bedrooms ~"~- Other 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. 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(tl/84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION.__ As certified by my seal affixed hereto and as of the val clarion date shown below, I verify that my investigation of this 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 further var fy that based on the information obtained '~ from the Mumc~pahty .... of Anchorage hies 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 ~ I~,, .r~..~.~¢'~ Address °ate Engineer's Seal DHEP APPROVAL Approved for ~/~e~z:~ bedrooms by ? Approved ~x Disapproved Terms of Conditional Approval 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 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 ~i~4UNIClPALITY OE ANCHORAGE DEPT. OF HEALTH & ENV~IRONMENTAL PROTECTION RECEIVED MUNICIPALITY OF ANCHORAGE (MOAi HEALTH AUTHORITY APPROVAL {HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: WELL DATA Well Classification ~.~ '~¢'"¢' ¥,~'~1~ IfA, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Ik~ f/~t: Date Completed Yield Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding .Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots 'To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date Comments · B. SEPTIC/HOLDING TANK DATA Datelnstalled '8~'/'~'¢- Size i'~.~.~-~4- No. of Compartments '~ Standpipes (Y/N) ~'¢~'~'%~ Air-fight Caps (Y/N) ~¢1~'=~, Foundation Cleanou,'t~((Y/N~ ~ ~¢~%-~-~ "~'~, Depression over Tank (Y/N) ~ Date Last Pumped ~-~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding'Tank: To Water-Supply Well ~ TO Property Line '~ ~'- / TO Water Main/Service Line / 1~/~f/~¢_ ; for ~ ~ Temporary Holding Tank Permit (Y/N) ~'~/~ To Building Foundation I I / To Disposal Field ~ / To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72 026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design Date Installed ,E~//~ Width of Field Square Feet of Absorption Area Z~O '~' Depression over Field (Y/N) Results of Last Adequacy Test ~/,~'/~ Separation Distance from Absorption Field: To Water-Supply Well Zoo To Building Foundation Lot To Water Main/Service Line .'~O ( ,~L_ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) ~"~ Date of Last Adequacy Test To Property Line [/~ ~''+ To Existing or Abandoned System on ; On Adjoining Lots [ ~;::~:~ / '-~' To Cutbank (if/present) ~/¢~ - ~o ~,.~ / D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at .~'~ Tested for Dimensions . Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA '* Check Permitted Bedroom Rating Against HAA Request ** I certify that I havg check~d, or conformed toatJ MOA and HAA guidelines in Signed Company _ effect on the date of this inspection. Receipt No. Date of Payment Amount: $ Page 2 of 2 72 026 (11/84} . ~ ',~' ,~. Engineer's .... ',~%'... c,-~,~ "...',, ~ ~ A ,,., ..... ..'x4~%' Seal ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA 99501 BILL SHEFFIELD, GOVERNOR Telephone: (~07) Address: 274-2533 To Whom it May Concern: /~ Q(~ According to records on file in this office the _ / ~ c,~t~ Water System is in compliance with the State Drinking Water Regulations Sincerely,