HomeMy WebLinkAboutSOUTHPARK #2 BLK 3 LT 17�1\ VJ/ -1
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211048
PID Number: 020-502-15
Dwelling: Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑® Upgrade
Name
Scott Brodt & Linda Leady
ABSORPTION FIELD
❑ Deep Trench ❑ Wide Trench ❑ Bed Zound
Site Address
15620 Jensen Circle
❑ Other
Phone
Number of Bedrooms
Soil Rating
—
Total depth fr original grade
14
GPD/SF
/% Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision
Block Lot
Southpark #2
3 17
Fill added above original gr 15'Gravel
Ft.
length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
I
Sewer
Total ab orption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
FI?
Ft.
Well
n/a
I
TANK l0 Septic ElS.T.E.P. ❑ Holding ElOther
Manufacturer
Greer
Capacity
1250 Gal.
Surface Water
n/a
I
Material
Number of compartments
Lot Line I
51+
NA
HDPE
2
FoundationV
V I
LIFT STATION
Manufacturer
Capacity
Remarks
Gal.
Alarm location
Electrical installed by
Installer
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
Northern Excavating
Drainfield co/MT3034
Inspector Pannone Engineering
BENCH MARK (Assumed elevation) 402.5 ft
Inspection 151 7/21/21 7/21/21
Location and description
3 d
2�d
4t„
BOTTOM STEP OF DECK AT PONT A
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
Date
OF A d
co
®�
49 9 6
Steven R Pannone
Septic System
CE 81401P
Approv
Date �0`7-Z�?��
DA
Note: this approval does not include well permit requirements.
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PANNONE ENG SVC LLC (C.I. DOHS) ""++ REVISIONS DATE
P.O. 90X 1807 PAL6.IER, AK 99645 -'q6 OF gCq'h, 9/28/2021
PHOtiE (907) 745-8200 FAX (907) 745-8201 = �P ''.... Sir '4 SCALE
SOUTHPARK #2 B3 L17
DRAWN ACP SCOTT BRODT & LINDA LEADY
15620 JENSEN CIR
C1.0 ANCHORAGE, AK
:...;
P.I.D. NO
020-502-15
Slewn R. Pannone '
y c, CE -8149 =
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PERMIT NO.
OSP211048
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MUNICIPALITY OF ANCHORAGE
On -Site Wmter& Wastewater Program
POBox 19805o 47O0Elmore Road
Anchorage, Alaska Bg519'OG5O Phone: 04 Fax: (8O7)348 -7S87
Permit Number: 0SP211048
Work Type: SepbcTankUpgnade
Tax Code Number: 02050215000
Site Legal Address: SUUTHPARK#28LK 3 L 17 G:3238
Site Mailing Address: 15G2OJENSENC|R.Anchorage
Owner: BRODTSCOTT E&
Design Engineer: PANNONEENGINEERING SERVICES
This permit is for the construction of:
[] Disposal Field 10Septic Tank 0Holding Tank 171 Privy
Effective Date
Expiration Date
Lot Size in Sq Ft:
Total Bedrooms:
2/26/2O21
2/2G/2022
M Private Well 0 Water Storage
All construction shall bminaccordance 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 (1 8AAC72) and Drinking Water Regulations (1 8AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65.Provide notification bycalling (807)343-7Q04(24/7).
4. From 'October 15b\April 15.a subaurfacesoi|uboorpUhnayotennunderconatructionduringhnozingwemthor
shall beeither:
a. Opened and Closed onthe same day, or
b. Covered, sealed, and heated hoprevent freezing
Received By:
Issued By:
Date
Date: _ZX2
4
MUNICIPALITY NC AGE
3,
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-502-15
Property owner(s) Scott Brodt & Linda Leady Day phone
Mailing address 15620 Jensen Circle, Anchorage, AK 99516
Site address same
Legal description (Sub'd., Block & Lot) Southpark #2, Block 3, Lot 17
Legal description (Township, Range & Section)
Lot Size 25,341 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
all that apply)
Absorption Field Initial Single Family (SF) X
w/wo ADU)
Septic Tank X Upgrade RX
Duplex D)
Holding Tank Renewal
Multiple Dwellings
Privy SF and/or D)
Private Well
Water Storage
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
Signature of property owner or authorized agent)
Permit/Rush Fees: $
225
Waiver Fees:
Date of Payment: O 2-, 2-(,p - 21 Date of Payment:
Receipt Number: (9 79 I 1 4 Receipt Number:
Permit No.
OSP211048
Waiver No.
Permit App_'- :-
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211048, Deb Wockenfuss, 02/26/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211048, Deb Wockenfuss, 02/26/21
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP211048
Work Type: SepticTank Upgrade
Tax Code Number: 02050215000
Site Legal Address: SOUTHPARK #2 BLK 3 LT 17 G:3236
Site Mailing Address: 15620 JENSEN CIR, Anchorage
Owner: BRODT SCOTT E &
Design Engineer: PANNONE ENGINEERING SERVICES
This permit is for the construction of:
Effective Date
Expiration Date:
Lot Size in Sq Ft
Total Bedrooms:
nt S�
of
DeI)artment
2/26/2021
2/26/2022
25341
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: 1 Date:
Issued By: Date: Z
4
MUNICIPALITY NC AGE
3,
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-502-15
Property owner(s) Scott Brodt & Linda Leady Day phone
Mailing address 15620 Jensen Circle, Anchorage, AK 99516
Site address same
Legal description (Sub'd., Block & Lot) Southpark #2, Block 3, Lot 17
Legal description (Township, Range & Section)
Lot Size 25,341
Sq. Ft.
Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) ❑X
(w/wo ADU)
Septic Tank
❑X
Upgrade RX
Duplex ❑
(D)
Holding Tank
❑
Renewal ❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
Signature of property owner or authorized agent)
Permit/Rush Fees: $225 Waiver Fees:
Date of Payment: O 2-, 2-(,p - 21 Date of Payment:
Receipt Number: (9 79 I 1 4 Receipt Number:
Permit No. OSP211048 Waiver No.
Permit App_'- :-
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211048, Deb Wockenfuss, 02/26/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211048, Deb Wockenfuss, 02/26/21
; MUNICIPALITY OF ANCHORAGE
~ ENVIRONMENTAL ENGINEERING DIVISION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE ~NEW
MAILING ADDRESS
/
LEGAE DESCRIPTION
LOCATION NO, OF BEDROOMS
~ Z Manufacturer Material No, of compartments
Liq. capacity in gallons Inside length Width Liquid dept~
~ IF HOME~DE:
, ~ Well Dwelling PERMIT NO.
~O~ DISTANCE TO:
~ ~ ~ Manufacturer Matarial ~iqu[d eopac[ty in ~allons
~ DISTANCE TO: Well
No, of lines Length of each li~e ~ Total length of lines Trenc w'dth Distance between lines
~ Top of tile to finish grade.~. ¢ ~ ~/ . Material beneath~lilo~ ~ inches Total ef ~so~i~ are~
kenflth Width Depth ~MIT ~O.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well I Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot llne PERMIT NO,
m Building foundation Sewer line Septic tank Absorption area(si
~ DISTANCE TO:
OTHER
PIPE MATERIALS
. ,,
72-013 (Rev, 3/78)
F EF..I,'I _ T NO:
[:,FITE ISSI_IE[:,:
RPF'L. I CFINT:
FIE:,E:,R ES S:
COt-,ITRCT PI'"IONE:
L FINDMRRI.<-VENTURE LTD
F' 0 BO:=.¢, ili654
FIN C H C~F:'.F]6 E., I::IK
]:45-4807
LEGFII... DE.:,L.R I F .
!._0~ :*..cE:
r Ih,, E:EE:.F.-:OEIME;:
SLIE:DIVIE;ION: SOUTH F'RRK ~2 LOT: t7
5:;ECTION: g 'TO.kINSHIP: 11N RRNGE: 3N
255:4:1. (E;Q. FT. OR RCRES)
4
BLOL-:K: Z
[..I_,TEE EfE/LL]H FIRE THE OF'TICflqE; H/}tlLI-IE, LE TO ~'OLI IN DE'--.,IFqqTNG '.r'}ltF.' :,EFTI_.
..,._,lEli. C:HC.3SE THE EF'TZON THRT BEST FITS 'T'OLI~: 2;ITE
DEi:"TH TO PIPE E:OTTC4'I
GRFt'¢EL DEPTFI ,::FT.
TOTRL. DEPTH (FT )
ORFt'v'EL F.!IDTN (FUT. ::'
EiRRVEL LENGTH (F'T. :,
[~RI,':I',.,'EL VO[_LIME <CU
TBNK SIZE <GRL. S)
SOIL. F.:R]' I NG
,::FT. ',
4 E~ 4.£~ q. Ca
55 E~ 5 -=-':5
'-q.. 5,~ 4-.5 7.5
25 2ELO 5 Ea
i(r_::t. L:I :+:* 56. 0 129. 0 **
6El. 5 58. 0 95. 5
±., 250. C~ :-P+: t., 250~ 8 ** i., 250.
299 257
........3_F.h,EL':' L.E:NGTH :::' --,..'F', FT. REL.-.!UIRES MLL.]t 'IFLE' E'llht':' ,::t-,IL-IT E~,,L. EEE. INb' .... -' ~'=','._, FT. ERCH)
· :+=:+: TR.t',tK t"IUST HR'CE I::FI' LE:RE;T T!.,.IO COI,'IF'RRTMENTL5
I C:ERT t F'T'
IF R
THEN
"FHRT:
±. I R.H F'FtMILIRR 1.4ITH THE REQUIREMENTS FOR ON-SITE SEWERS FIND WELLS FIS SET
FORTFI B'¢ TNE HUNICIPRLIT'¢ OF RNCHORRGE clMOR) RND THE S]~RTE OF' RLFISKR.
2. I 14ILL INSTFILL THE S'-P_:JTEI,.1 IN RCE:ORDRNCE kll]'H RLL MOFI CODES RND REGULFITIONS..
R. ND IN COI,"IPL. IRI'.,iCE HITH THE DESIGN CFRITERIRR OF TI-IlS PER. MIT.
t HILL RDHERE TO RLL MOFI RND STRTE OF FtLRSKR REQUIREMENTS FOR THE SET BRCK
[)IS'I"RNCES FROM R.N'¢ E',?.','IS"I"INO HELL, HRSTEt.4FF[ER DISPOSRL E;"r'E;TEI"t OR PUBLIC:
E;E:I..IERRGE S'¢E;TEM ON ;"HIS OR RN"r' RDJRCENT OR NERRB? LOT.
I L~ND'ERSTR'Nt-':' TNRT THIS PERMIT IS VFtLI[:' FOR R I,'IR;:4INLIM OF 4 BEE:'ROONS R'ND
R.N'¢ ENL..RRGEHENT HI.L[_ REQUIRE; FIN RDDITIONRL F'ERMIT.
DLDLLL. E IN RN RREFI COVER[E:, E,'-r MOFI BLtlLE:,ING LuEE.:,.,
L. IFT _,'TH] t_iq I=, ' '
':::1.2:' RN ELE..F,.IL. hL PERI"IIT RND II,,I=,FEU¥I_i'~ I,IU:,F E,E uE, TMINE[. (2) H_, E, UILT_,
HILL NE;" FF.- RPPRO',,/E[:' I,.IITHEILIT FIt',t ELE_.TF luRE INSPECTION RLFuF..T., FIND "2:' THE
RF'PLICFINTU[ F'INDfq~, .I:I~:>-',/EN]"URE LTD /~~
11600 ¢4NGE
(~O7) $~-~ ~ PERCOLATION
TEST
SOILS LOG - PERCOLATION TEST
SLOPE
SITE
cD .~.4~-¢V~
6 C -va
7
8
9
10
11
12-
13-
14-
15-
16
17-
18-
19-
20-
WAS GROUND WATER
~L~'~ '~¢~-~ '~-~'~ ~NOOUNTERED?
E
DEPTH?IF YES, ATWHAT- ~
Gross Net Depth to Net
Reading Date Time Time Water Drop
!IPALITy OF AN ~HORAGF
')NMENTAL PRC r'ECTION
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN ~ , FT AND FT
COMMENTS
PERFORMED BY: "~'T'~'~.. ,~(-k'/~.'"N~ CERTIFIED BY: DATE:.
?"'?.UNtOIPALITY OF ANCHORAGE 'f--,~ ~Yd /~'
, ,~'~' .~, DEPARTMENT OF HEALTH ANDENVIRONMEN~ALH;OTECTION ~., ~'r~COLr,~m':
.... %~¢ .... SOILS LOG- PERCOLATION TEST pq,:~ '~ '¢ % ~: ~' '~
PERFORMED FOR:~
__ DATE PERFORMED:
13
14
15
16
17
11
' C. Reid, Jr. ,*' ~.,
~o. 2251.E ~'
COMMENT$~
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
Reading gete
!
q H,~O
¢
Time
~ '~ ;;..
Net 'Depth to
Time
Net
Drop
,/~
,/~
,/~
·/,/'
PERCOLATION RATE
TEST RUN BETWEEN
, '"'-~ ~ minutes/inch)
FT AND FT
CERTIFIED BY:
72,008 (6.179)
MUN J'CHWALITY OF ANCHORAGE
0_
S�'a
Development Services Department r- Phone. 907-343-7904
On -Site Water & Wastewater Section-' Fax: 907-343-7997
Certificate Of On -Site Systems -Approval
Parcel I.D. 020-502-15
1. GENERAL INFORMATION
Complete legal description
Southpark #2 133 L17
Location (site address) 15620 Jensen Circle
Current property owner(s)
Mailing address
Real estate agent
2. TYPE OF DWELLING:
F1 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Expiration Date: l -2q - ZD Z3
Day phone
Day phone
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
0
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 $ 5.50
Date of Payment 9/-ZQlZ l
Receipt Number _ 0-3(,,-7-7/-'
COSA# _05C2( I5g2
Waiver Fee $
Date of Payment
Receipt Number
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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA
COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time
of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on
the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not
guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot
provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole
benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly
recommends buyers hire their own engineer to evaluate this report.
Name of Firm Pannone Engineering Services
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone P.E.
6. DSD SIGNATURE
System #1 Approved for A bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for
Phone (907) 745-8200
Date
bedrooms, with the following stipulations:
�«ccccccrrr
UF
J ON—SITE `9
WATER AND
Original Certificate Date: ( 0 — 7 --
The
The Municipality of Anchorage 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
Legal Description: Southpark #2 B3 L17
If more than 1 septic system on lot: COSA Checklist # 1 of 1
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.
Comments Public water
B. TANK DATA
Age of tank(s) °avi "' years
Tank type/material "°p`'e°t`
Measured operating fluid level in septic tank new
ril Standpipes/foundation cleanout per record drawing
Date of pumping new tank
D. ABSORPTION FIELD DATA
Which system tested (date installed) 7/17/84
H ALL standpipes present per record drawing
Total measured depth from grade 10.5 ft (max)
Measured depth to pipe invert from grade 4.5 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective sfl
0 Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID: 020-502-15
Structure served by this system 1
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
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 9/29/21
Results 0 Pass For 4 bedrooms
Fluid depth prior to test 0 in
Water added 600 gal
New depth 0 in
Elapsed time 120 min
Final fluid depth 0 in
Absorption rate '600 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
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
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
❑ Yes
if No ft
Neighboring Tank > 100' ❑ Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' ❑ Yes
if No ft
Neighboring Absorption Fields > 100'
✓❑ Yes if No ft
Water Main > 10'✓❑
Animal Containment > 50' ❑ Yes
if No ft
❑ Yes
if No
ft
✓0 Yes if No ft
Water Service Line > 10'
n
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
Community Sewer Main > 75' ❑Yes
if No
ft
❑ 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
Surface Water > 100'
® Yes if No ft
Property Line > 5'
Yes
Yes
if No
ft
Wells on Adjacent Lots:
0
Absorption Field > 5'
❑✓
Yes
if No
ft
Private Wells > 100'
✓❑ Yes if No ft
Water Main > 10'✓❑
ft
Yes
if No
ft
Community Wells > 200'
✓0 Yes if No ft
Water Service Line > 10'
n
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
If absorption field is under driveway comment below
Property Line > 10'
0
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
0
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
0
Yes
if No
ft
Community Wells > 200' ❑✓ Yes if No ft
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l 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.
COSA Checklist yellow sheet
P.O. Box 196650
MUNICIPALITYOFANCHORAGE ;' ' - -
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environrnenta[ Services
On-Site Services Section
Anchorage, Alaska 99519-6650
. . h;ViRONM~NTAL SERVICES DIVISION
343-4744 -
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAl. INFORMATION
Complete legal description /-o f ,'~
Location (site address or directions)
Property owner
Mailing address
Lending agency ,v'..4.
Mailing address
Day phone ~' YJ'-'- 7/d'?
,4,~ c4 o ~',~.7~J .4-&
Day phone
Agent ~2~ R,,~ Dy,~,~,',,;¢
Address ~111 ~ ",_c/p -C,k-,~L¢
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
Day phone
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
attesting to the legality and status of system.
72-925 (Rev. 1/91) Front MOA#21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixea hereto and as of the vaudation date shown below, i verify that my
~nvestigation of this Health Authority Approval application snows 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
suoply and/or wastewater disposa~ system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
NameofFirm M:'/,~//cp '/-,~4nt'~/ -¢~r~,,'c~- Phone
Address
EngineeCs signature
6. DHHS SIGNATURE
Date..
Approved for FO ~1~ bedrooms.
I::)isapproved.
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 !s not
responsible for errors or omissions in the professional engineer's work.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
LegalDescription: J..~,/ /7~ ~/~¢/~ .5-oc<~%?~-/~ :~. ParcelI.D.: O~' ~'~'8 ,5-8
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to
FROM WELL LOG
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Date of test
Static water level
Well production g.p.m.
g.p.m.
WATER SAMPLE RESULTS:
Coliform Nitrate Other bacteria
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed 7/8~' Tank size I~'e~r~el Number of Compartments ~- .Cleanouts (Y/N)___
Foundation cleanout (Y/N) ~' Depression (Y/N) ~/ High water alarm (Y/N) ,~./~.
Y
Date of Pumping 7/~{ 78 Pumper ~£,~,~ cs
C. ABSORPTION FIELD DATA
Date installed 7
Length .fo ~ Width
Effective absorption area
Date of adequacy test ~'
Soilrating (g.p.d./fForff2/bdrm) I~?- ~' Systemtype
Gravel thickness below pipe
Monitoring Tube present (Y/N). 'r'
Results (Pass/Fail)
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
Total depth i~'
__ Depression over field (Y/N). ~'
For 5' bedrooms
Fluid depth in absorption field before test (in.); J'¢'" .I.mmediatelyafter,~Z~gal. wateradded (in.): O"g
Fluid depth ,,5-5- '~-/~ (ins) Minutes later: ~d' Abs°rptio~ate~,, ff, i ' ~-2 g.p.d, . , ..
D. LIFT STATION fJ.,4[,
Date installed
Manhole/Access (Y/N)
High water alarm level att
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot -
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots -
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK ON LOT TO:
Foundation I~-' Properly line 5'~' Absorption field
Water main/service line ~> ~,~' Surface water/drainage ",> tod '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line __ ~'~" Building foundation ~'-'
Surface water ;> ~4' '
Curtain drain tv'¢,,~ _c~ ,,-~
F, ENGINEER'S CI=RTIFICATION
II~
Wells on adjacent lots
Driveway. parking/vehicle storage area
Wells on adjacent lets ~ '~'d '
Water main/service line
I certify that I have determined thru field inspections and review of Municipal records (haF~i~':e':~' systems are
in conformance with MOA HAA guidelines in effect on this date. , '~' ;' ', ..~.~ ~,~ "'
Signature ~'~ ,~.
Engineer's Name
Date ~/~/¢~
HAA Fee $ ~0~) -~
Date of Payment__ '7/~/~ C
Receipt Number_0 ~O,q ~ f'".~,-~/ ~' ~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ~"~(~ - ~,~- ./~ NAA# ~D
1. GENERAL INFORMATION
Complete legal description LoT 1'7 BLk' 3
Location (site address or directions)
Property owner
Mailing address
Lending agency
~.~.
Day phone
d '
Day phone
Mailing address.
Agent J~c~ gLg~ ~'~ ~'IAX
Address 2o~,eo Co,bet/A,
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
NOTE:
Day phone
:2-7G- 2v~l
Individual well
Community well v/
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
Public sewer
NOTE:
If community wastewater system, p~'ovide 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 F'LA'rTOP TE~:H 5VC5 Phone ~¢5-- 13E~-
Address JHS$O ECHo z-r, ~fCg,, t~K
Engineer's signature of'~ ~. ~ Date
DHHS SIGNATURE
/~ Approved for
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additionai 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 DH HS 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.
72q725 (Rev, 1/91) Back MOA ~21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LoT 17~ B~-K 3.. 5r~u'T~IPA,~K. ~2
Parcel I.D. O,~_~ E:).-~ ~ -~--~
A. Well Data
Well type "A"
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Wires properly protected (Y/N)
FROM WELL LOG
g.p.m.
AT INSPECTION
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
.g.p.m.
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
'7- /~ 7/~
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size J25b (~A L Compartments 2.
Foundation cleanout (Y/N) Y Depression (Y/N)
Alarm tested (Y/N)
Pumper J
N
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot N.~, On adjacent lots
To property line Ho' '~,~ ¢.o, Absorption field
Surface water/drainage ~> Ioo '
Foundation J$ F,~oH ('.D,
Water main/service line ~ Lo '
CONTINUED ON BACK PAGE
72-026 (3/93)* Front
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)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed -//? L(
Length 50 Width
Total absorption area mOO
Date of adequacy test
On adjacent lots
Water level in absorption field before test ~"i"
Peroxide treatment (past 12 months) (Y/N) ~¢ k'~o~,~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot N.A~
To building foundation 15' /
On adjacent lots ~ Nc,'
Sudace water ~ ~oo'
Cudain drain No,4~ oBSg~V~b
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA ~
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Surface water
Soil rating (GPD/FF) .78 G~'~/F~~ System type
Gravel thickness $ Total depth I o
Cleanout present (Y/N) ¥' Depression over field (Y/N)
Results (pass/fail) ~'/~ 55 for
After test ~ I "
Bedrooms
If yes, give date
On adjacent lots N, ,4. Properly line
To existing or abandoned system on lot
Cutbank ~4.,~. Water main/service line
Driveway, parking/vehicle storage area ¢ '¢o '
s ~nspection.
Signature
Engineer's Name
Date '~
HAA Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
DEPT. OF ENVIRONMENTAL CONSERVATION
WALTER J. HICKEL, GOVERNOR
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
July 19, 1993
(907) 349-7755
Mr. Ted Moore
Flattop Technical
SUBJECT: Lt. 17, BK 3 (15620 Jensen Circle); South Park Terrace Sub. #2
Class "A" Public Water System, PWSlD #213475
Dear Mr. Moore:
I have completed a review of this office's files concerning the monitoring status of the
above-referenced Class "A" Public Water System and found the following:
The last satisfactory Total Coliform Bacteria Sample results was
submitted to this Department on July 6, 1993. This does meet the
provisions of 18 AAC 80.200(a) of the State Drinking Water
Regulations.
The last inorganic Chemical Contaminants Sample results were
submitted to this Department on July 6, 1993. This does meet the
provisions of 18 AAC 80.200(a).
The last Radioactive Contaminants Sample results were submitted to
the Department on December 12, 1992. This .does meet the
provisions of 18 AAC 80.200(a), State Drinking Water Regulations.
The last Organic Chemical Contaminants/Volatile Organic Chemical
(VOC) were submitted to this Department on November 8, 1991.
Based on analysis of the previous VOC samples results have been
satisfactory. This does meet the provisions of 18 AAC 80.200(a),
State Drinking Water Regulations.
Issuance of this letter does not imply that the above-referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations. Unless
otherwise noted, this letter is valid for 30 days and is for the specified legal description
noted above only.
Mr. Ted Moore 2 July 19, 1993
If you have any questions on the above information, please do not hesitate to contaot this
office at 349-7755.
Sincerely, //'¢ ,¢
Michael Lu
Environmental Eng. Asst. II
MLU/cf
enclosure
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
Appl,cation Date 11~/'~ /
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~~- U4~.~elephone: Home
(c)
Business
Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address '-
(e) Real Estate company and Agent
Address
(f)
Telephone
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family ~ Multi-Family
Number Of Bedrooms
Other
WATER SUPPLY
Individual Well [] Community I~ 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 Environ mental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (~1/84}
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investlgr, fl
Authority Approval shows that the on-site water supp[y and/or wastewater disposal system is Safe, function.51
for the number of bedrooms and type of structure indicated herein. I further verify that based on the inform§~Hb;t
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulati,,~
the date of this inspection.,~.~
Name of Firm ~/~l-t~'/.;~J,~;~',~ &~'~,f,~ ~c~S~- Telephone ,-,~"*'/~'"'-- ~'~<:::~'
Address /'/' ~:~-~ ~-~'~'¢'~ ,)~} /'~~ //~'/ ~_~.=,~
...................
- .........
Approved for ~0~ bedrooms by ate
Approved ~ Disapproved
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
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date
(a) Legal DescTi. iption (include_lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicants Name ~f1-~%-)~ ~-~--~_ ~ ~9~P~--Teleph°ne - Home Business
Applicants Address. ~ ~ , ~c~x LI -
(c)
(d)
Applicant is (check one) Lending Institution
Buyer ~--~ ; Other ~ (explain);
Lending InStitution ~
Address
(e) Real Estate Coo & Agent
(f)
Address
~,yye of Residence
Single-Family~
Number of Bedrooms
Mail the HAA to the f?llowzng address: ~, ~.;~
Water Supply
Note: If community well 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 1 of 2]
0
~ngineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below,
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 regula-
tions in effect on the date of this inspection°
Name of Firm ~-C~tCJ ~ ~.~(~ Telephone
Address
Date '~/~f- ~/~:~'~-- ~o ....=j
(ENGINEER SEAL)
DHEP Approval
Approved for ~J bedrooms '
Approved ~ Disapproved
CAUTION
THE I~UNICIPALITY OF ANCHORAGE DEPARTMENT OF NEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY B~N INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA, THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. ~iPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED, THE MUNICIPALITY-OF ~NCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK°
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19 -84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
WELL DATA
Well Classification
Well Log P~esent (~
If A, B, c~ C, D.E.C. ApproVed(Y/N) ~-~
Date Oumpleted Yield
Total Depth ~ ~se~to
Static Water Level '~P~mp Set At
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances f~c~n Well:
To Septic/Nolding Tank on Lot ;
To Nearest Edge of Absorption Field o/Dw~ot ;
To Nearest Public Hewer Line// To
Cleancut/Manhole J To Nearest Sewer
Collected/~l~ ; l~te
Water Sample ~est
Water Sampl~ Re~lts
C~l~ents
Depth of G~outing
on Casing (Y/N)
Around Wellhead (Y/N)
oining Lots
ioiningLots
PublicS ewer
Line on Lot
IQ,~ Z
B. SEPTIC/HOLDING TANK DATA
Date Installed ~v~T ( ~_Size !~_~.D No. of Compartments
Standpipes (Y/N) ~=-~ Air-tight Caps (Y/N)¥~i% Foundation Cleanout (Y/N)~
Depression over Tank (y/N)~.D Date Last Pumped
Pumping/Maintenance Contzact cn File (Y/N) ~/~ for ~.]
Holding Tank High-Water Alarm (Y/N) ~A~r Temporary Holding Tank Permit (Y/N)~
Separation Distances f~om Septic/Holding Tank:
To Water-Supply Well ~'~iD "~
To Property Line ~ C) '" '"'~-'-
TO Water Main/Service Line
Course ~
To Building Foundation I_~-/
To Disposal Field ~ ~
To Stream, Pond, Lake, c~ Major Drainage
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Length of Field_
Depth of Field I~r
Gravel Bed Thickness
Standpipes P~esent
Date of Last Adequacy Test
Square Feet of Absorption A~ea ~ ~
Depression over Field (Y/N) ~ 63
Results of Last Adequacy Test ~ f ~ _
Separation Distance from Absorption Field:
To Water-Supply Well ~.~-~> .-~- __ To P~operty Line ~-7 f --~
To Building Foundation I~-- ~ To Existing or Abandoned System on
Lot ~.3 [ ~- ; On Adjoining Lots __ ~ ( - ~
To Wate~ Main/Service Line ~/.$- To Cutbar~{(if present)
To Stream/Pond/Lake/c~ Majo~ D~ainage Cou~se ~ ~ ~c-
To Driveway, Parking Area, o~ Vehicle Storage Area ~O/ .-I-
Con~nents . ~
D. LIFT STATION
Date Installed
Din~nsions
Siz~ in Gallons ~--''~ho]~/Access !Y/N) ' ,.,-"
"Pump On" Level at Off" Level at
High Water Alarm Level a~/ ~ --Vent (__Y__~)
/
Tested fo:~ / Pumping C~~t. Meets MOA
Electrical Codes(Y~
Cor~0ents / ,
** Check Permitted Bed~oomRatingAgainst HAARequest
I ~tify that I have checked, ~ified, o~ ~nfo~d to all ~A H~ ~i~].i~s, in effect
date of this ' ~i~. ·
Signed Date ~}~.
KBt/d5/s
[Page 2 of 2]
2-15-84
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
'ANCHORAGE, ALASKA gg501
BILL SHEFFIELD, GOVERNOR
Telephone; (907)
Address:
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,