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Home My WebLink AboutSPERSTAD #2 BLK 5 LT 12 MUNICIPALITY OF ANCHORAG,: DEPARTMENT OF HEALTH & HUMAN SERVlGES 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.# ~'\ ~-(.~-'~ 1. GENERAL INFORMATION Location (site address or directions) l '~ ~ ~ (' '~'/-~_~(~-- Property owner ~1~ L. ~~~ Dayphone Mailing address ~ ~ ~ ~.~ ~PI~ ~ ~ Lending agency ~~ ~~ ~ Day phone Mailing address ~0 ~*~_-' ~ ~.~ / ~0~,~¢~ Agent ~~% ~ ~IC~ ] , Dayphone Address ~~) ~ ~~ ~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 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. 72-025 (Rev. 1/91) Front MOAl~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 affection the date of this ~spection. Name of Firm ~(~lL_f_.fl ~"NL ~'~ ,~.[~m.l~/ '(~y-- Phone~4~ --~ )~/~ Address, /~O ~J¢~j ~[ ~ -~' ' .~ Engineers signature {/( )~%.~,( ~/*~ ~ ~ Date ~/~/~'~ DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 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. 72-025 [Rev. 1/91) Back MOA ~r21 Legal Description: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502. Anchorage, Alaska 99501. E D Health Authority Approval Checklist ~ (/'~5 5~::?¢~'r-~p ~(k,garcel I.D.: dUN 2 1 ]996 A. WELL DATA Munlcipuii,y u~ Dept. Health & Human Se vices Well type Log present (Y/N) ~ ~ Date completed Total depth ~{~ ~;~'~."p, ~ Cased to Sanitary seal (Y/N Y~¢~ ~4A¢_.~ Lk/. If A, B, or C, attach ADEC letter. ADEC water system number Casing height (above ground) Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well p,roduction g.p.m. ~ WATER SAMPLE RESULTS: Coliform O (' ~ Date of sample:_ , &] l Il~ Collected by: I ' DePression (Y/N) S. SEPTIC/HOLDING TANK,..D,~.TA ' Date installed ~/~ ~-) Tank size Foundation cleanout (Y/N) k.~ AT INSPECTION g.p.m. bacteria Number of Compartments ( Cleanouts (Y/N). T J~ High water alarm (Y/N) ~ Date of Pumping /_,~' ! ~[~ ~ Pumper ~~ C. ABSORPTION FIELD DATA Date installed ~r¢i¢-.~ ~,J. ~ l¢[~--~Soil rating (g.p.d./fF or fF/bdrm) R- System type Length' /[LO ~ Width ~--. Effective absorption area ~(~ 0 Date of adequacy tes, ~ I¢((~ Results(Pass/Fail) ~:~/~ For ¢ Fluid depth in ~~¢~re test (in.); ~atel, afer ~ ~ __ gal. water added (in.): Fluid depth ~ (ins) Minutes later: ~l~ Absorption rate = 7 47 ¢ g.p.d. Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date ~ Gravel thickness below pipe ¢-~ ~ Total depth Monitoring Tube present (Y/N) ~ Depression ever field (Y/N) bedrooms 72-026 (Rev. 3/96)* LIFT STATION Date installed :Ilt~¢' Manhole/Access (Y/N) High water alarm level at* Size in gallons "Pump on" level at* *Datum "Pump off" level at* Cycles tested SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: t Septic/holding tank on lot · ~0 ?0 ~, 0. Absorption field on lot J % ~ ~ " On adjacent lots On adjacent lots Public sewer main Sewer/septic service line Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~' ! Property line ~ z~ ~ Water main/service line ~l/~' Surface water/drainage ~1/~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ~. "~ f t Surface water Curtain drain Absorption field ~' '~ I Wells on adjacent lots ),4,~0~ ~¢~"~ ,¢/' Building foundation ~ ~ Water main/service line h[ //4 XO~I~' ~T~r.~¢~., parking/vehicle storage,arena ~ O ' . ~0¢~ Wells onadjacentlots 10.,~_ ¢~ F, ENGINEER'S CERTIFICATION ' Enginee~"s Name Date '. ~ / rmined thru f ~lines in effect on this date. inspections and review of Municipal rec~'~. ,~,. ~b~t~rns are HAAFee $ ~OO.OO Date of Payment ~ Receipt Number (~ ~'(:~'~% I 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number NORTHERN TESTING LABORATORIES, INC. :~,'J:~0 INI)IJ~-;H{I^I ^V~{NUC rAIrtHANK~;. ALASKA 0!)/01 (907) 4ff,~ 0110 · I AX 45E~ :{l~b Rick I{arvey 13720 Davis Road Anchorage AK 99516 OUr Lab #: You~ Sample ID: Sample Matrix, 13021 Back Road Water Report Date: 06/13/96 Date Arrived: 06/12/96 Date Sampled: 06/11/96 Time Sampled: 1345 Collected By: MDL = Method Detection Limit * Fla~ Definition~ Below Regulatory Mia, Above Regulatory Max, Date Lab~ Method Parameter . Unit~ Results * MDL Preparad Analyze F161~05 EPA 300,0 Nitrate-N m~/A <MDL 0,03 06/12/9, Vice NORTHERN TESTING LABORATORIES, INC. 3330 INDtJSIlUAL AVENUE FAIFtBANI<S, Al A~:;KA 99701 (!.)[)/) 4b¢.i-:~11(; · FAX 45B 31;'h (l(')05 ~;Clt(.1ON SI'[~EET ANC, I IOnA£1E, ALA~I<A 99518 (~JE)7) 34E)10110 · ['AX ;/40. DRINKING WATER ANALYSIS REPORT FOR TOTAL COLIFORM BACTERIA Rick Harvey 13720 Davis Rd. Anchorage, AK 99516 Public Water System I.D.# Date Received: Date Analyzed: Date Reported: Next Sample Due: Comments: Phone No. U Purchase Order No. POS ND Collected by: WY TNTC Sample Type: CG Routine Untreated HSM Method of Analysis: Membrane Filtration SA ~ 06/11/96 Time Received: 14:00 06/12/96 Time Analyzed: 15:10 06/14/96 Time Reported: 07:28 Old : Comments: R : NT : Satisfactory Unsatisfactory Positive Test Result None Detected Too Numerous To Count (>200 Colonies) Confluent 8rowth Heavy Sediment Masking, Results May Not Be Reliable Sample Age >30 Hours But <48 Hours, Results May Not Be Reliable Sample Age >48 Hours, Too Old For Ana)ysis Resample Required No Test * # Colonies/lO0 ml ** # Colonies/mi Sample Sample Total* Fecal* Other* NPC** Date Time Coliform Coliform Bacteria Result Lab~ Location Comments :n~i~onmenta 1 Analyst Date: 8/10/88 Memo to file: Lot 12 Blk. 5 Sperstad #2 From: D.N. Bolles, On-site Services This property was developed as, and continues to be, a duplex. On 8/23/86 a HAA was submitted for approvel marked as a single family residence but also noted as a duplex. It was approved as a single family residence. Where as this office does not possess the authority to approve multifamily dwellings the HAA has been permited to expire and the parties notified It should be noted therefore that this office will not permit any future HAA's or permits for this parcel while it remains a multifamily dwelling. MUNICIPALITY OF ANCHORAGE DE?ARTMENT 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 LEGAL DESCRIPTION LOCATION NO. OF22ROOMS DISTANCE TO: Manufacturer L q. capacity in ga Ions Well Absorption area Dwelling PERMIT NO. Material No. of compartments I Inside length Width Liquid depth IF HOMEMADE: DISTANCE TO: Well I Dwelling PERMIT NO. Manufacturer Liquid capacity in gallons Foundation~, O t PERMIT NO. ~000 Distance between lines DISTANCE TO: Well / No. of lines/ Length ofcbino Top of tile to finish~a~de b-~O ' Length Width Total le~81ines Material beneath tile Depth Material Nearest l? ~)ne, Tren,~ ~/~;Jt, inches ~ /-- ~) inches Total effective absorption are~ 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 SQIL TEST RATING INSTALLER REMARKS APPROVED .... /.~ DATE , LEGAL 72-013 (Rev. 3j~8) DEPRRTMENT OF HERLTH RND ENVIRONMENTRL PROTECTION 825 "L" STREET., RNCHORRGE., RK. 9L~.50:1. 264-4728 0~4---~ I l'E SEb~ER LIPCiRF~[:,E PERMII" NO. ( 880864 ) ,.,~._.J CR. RNBERR'¢ RD LOCRTION BRCK RD LEGRL LOT ':~2 BLk~ ~RER~TRD ~ -~ TVPE OF SOIL RBSORPTION SVSTEM IS: TRENCH LOT SIZE 2200EI = .... F-E FEET MR;:.¢IMUM NUMBER OF E:EDF.'.OOMS = 4 Lc, OIL RRTING <SIg. FT,,"BR)= .~2.~ THE RE[.)._IRED SIZE I]IF THE SOIL RE:SCIRPTII]N~EM IS: IZ:.EZP'-Ftq= ~L;~ LE~-~,3TH= ~ r_~RR"..-"~:£L. £';,E-'F'TH= :=: THE LENGTH DIMENSION :iS THE LENGTH (IN FEET) OF' THE TRENCH OR DRRINFIELD. THE DEPTH OF Ft TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF TFIE GROUN[.', RND THE BO'f'TOM OF THE ENCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTN IS 'THE MINIMUM DEPTH OF GRR',/EL BETWEEN THE OUTFRLL PIPE RND ]'HE BOTTOM OF THE E',,.ICRVRTION (IN FEET:). PERMIT RPPLICRNT HFIS THE RESPONSIBILIT'-? TO INFORM THIS DEPRRTMENT DURING THE INSTRLLRTION INSPECTIONS OF RN'-r' WELLS RD..IRCENT TO THIS PROPERTV RND THE NUMBER OF RESIDENCES THRT THE WELl_ WILL SERVE. -['FIE, ,:'..:_'~:' ::, I i'-.! ~---_. F" F£ C:'T' ]:. 0 r-.I ~_4 RF][-]: R E r2. LI. I F~ E [;, ERCKFILLING OF RNV SVSTEM WITHOUT FINRL INSPECTION RND RPPRO',,,'RL B'¢ THIS [EFRRTMENT WII_L BE =,UE, JECT TO FRU.z, ECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL S'¢STEM IS ~L00 FEET FOR R PR IVRTE WELl,. OR $50 TO 20~3 FEET FROM R PUBL, IC WELL DEPENDING UPON THE TVPE OF PI. JBLIC 14ELL MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVRTE SEI.,,IER LINE IS 25 FEET RND TO R COMMUNIT'¢ SEWER LINE IS 75 FEET. OTHER REI;!UIREMENTS MR¥ RPPI_N-'. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INS'FRLLRTION. I CERTIFV THRT ±: I RM FRMILIRF.: WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH B"r' THE MUNICIPRLIT°T' OF RNCHORRGE. 2: I WILL INSTRLL THE S"r'STEM IN RCCORDRNCE WITH THE CODES. ]:: I LNDERE;TRN£:, THRT THE ON-SITE S,~4ER S'T'STEM MR'¢ REQUIRE ENLRRGEMENT IF THE S 113NE[:,: ____~~ ............... I / .EN'rER I SES ISSUE[:, 3 _6_ _~ ..... DRTE .............. V4. 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99602 276-2221' SOILS LOG- PERCOLATION TEST ySOILS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: DATE PERFORMED:, SITE PLAN ' ~ ~J~ ~1 10 11 12 13 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH7 14 16 17 18 19 20 Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND -- FT COMMENTS PERFORMED BY: 72-008 (7/76) CERTIFIED BY: DATE: QGRE "R ANCHORAGE AREA BOP "GH Department of Environmental (~uality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM PHONE SEPTIC TANK: DISTANCE ~Ct~ FROM WELL INSIDE LENGTH · ('~//~ NUMBER OF MANUFACTURER ~'~ OD I~.; MATERIAL ~O~O 0-~- ~ +C~ COMPARTMENTS INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY)~~)'~(~) GALLONS. SEEPAGE PIT: NUMBER OF PITS 1 . DIAMETER __OR WIDTH, LENGTH DEPTH ~ / LINING MATERIA~(~~I~B SIZE: DIAMETER DEPTH DISTANCE FROM: WELL ~ ~) ' ' TOTAL EFFECTIVE ~4~0S BUILDING FOUNDATION~O NEAREST LOT LIN~O ABSORPTION AREA (WALL AREA) Q. FT. ADDITIONAL ABSORPTION WELL: TYPE (~/~ CONSTRUCTION BUILDING "~ P't I NEAREST FOUNDATION ~--)~' ., LOT LINE.. CESSPOOL_ OTHER SOURCES APPROVED DISAPPROVED NEAREST SEWER LINE. REMARKS DEPTH ~t"~ ~ DISTANCE FROM: SEPTIC SEEPAGE TANK SYSTEM DISTANCES: INSTALLED B Y:~) PIPE MATERIAL: '~ ~5~-G'~+ ~l~Ol~J LOT SLOPE: Form No. EQ.031 DIAGRAM OF SYSTEM GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT pERMIT NO, INSTALLATION LOCATION ~";~} "E GAL D ESCR,PT,ON INSTALLATION OF: SEPTIC TANK '~ SEEPAGE PIT TO BE INSTALLED BY F~NANCED THROUGH ~.~ DRAIN FIELD NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. ,. SEEPAGE AREA B, E : ::/ MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK ~ / FOUNDATION TO SEEPAGE PIT -- SEPTIC TANK TO SEEPAGE PiT WALL /'~ TO NEAREST LOT LINE. / WELL TO SEPTIC TANK DRAIN FIELD / ., DRAIN FIELD ALSO CONSIDER AREA WELLS. ., SEEPAGE PIT . SEPTIC TANK,--~'~0 ~' SEEPAGE PIT ,//6~ DRAIN PIELD GRAVEL BACKFILL CONFORM TO BOROUGH REGULA'rlONS REGARDING INSTALLATION. I~IAGRAM Of ~YSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE, DATE APPLICANT'S SIGNATURE FORM NO. EQ-016 - .. G E. TI i ,NCHORAGE AREA *ROUGH /) , .~?'~ m' HEALTH DEPARTMENT (' ,u~ ~2'&gggle St~/ ~' Anchorage, Ala&a 99501 279-2511 APPLICATIONT0 INSTALL: SEPTIOTANK~,SEEPA~EPIT FINANCED THROUGH ~ Z~ , . TO BE INSTALLED BY . . ASDESC~~. SIZE OF UNITTO BESERVED" DISTANCES: ";: -/ HEALTH AUTHORITY OR LICENSED DESIGNER I certify that I am familiar with the requh'ements of Greater AnchorageArea Borough Ordinance No. 28-68 and tha.t thd above described system is in accordance with said code. //,~/ ~/~ ~/~ / /~ / '~? .,, ~ /' - ~/ -~) ~ 7- ,/ / ...... (. ~ ,5p:,.,,r:,'~ Fe,'?.o.: ./'n ~'Z/ /~(~. rocordino Prc. c;ncl, Alaska, end that tho 011te {]. Kelsy S.P,,A. [;ox 1414 g't nc er~l ,v, I,ynr~ Coad Sanitarian LC/ko 3=nuar. y 6, 1972 M~,. 01]~e ~ene Kelsey S~. P',t. A l~ox ]414 t~ On APril 5, 1971 YOu Obtained a Po~m~C f~om '~h~s ment fop tho Jns~allat-lon of an on.-st~e Depap~., be inStal]od at the above location, sewe~ system to ins'~alled op ~f YOu u:ish ,youp ih~int~ kel)~ valid fi]eS, - . Stncerel,y, C. Stto. Hcl(echnie [~nvir, onn~ental Control O~ffcer st; MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SiTE SEWER AND WATER FACILITY 264-4720 Application Date 6/].8/86 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) LOT 12 BLK 5 SPERSTAD SUBDIVISION 2, T12N,R3W Location (address or directions) 13021 Back Road; Anchorage, AK 99515 (b) Applicant Name James Stonebraker Telephone:Home Applicant Address 13021 Back Road; Anchnraga: (c) 345-4034 Business 562-2575 AK 99515 Applicant is (check one): Lending Institution []; Owner/builder [] ;Buyer []; Other [] (explain); (d) Lending lnstitution Alaska Mutual Bank Telephone Address 1500 W Bensoj~. Blvd; Anchorage.: AK (e) Real Estate Company and Agent N/A Address (f) 258-7890 Telephone Mail the HAA to the following address: , L,:q~e~__,~e~ce r 13021 Back Road Anchorage, AK 99515 TYPE OF RESIDENCE Single-Family[] Multi-Family[] Other Duplex Number of Bedrooms 4 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. 72-025 (11/84) Page 1 of 2 ENGINEERING FIRM PROVI[ ..~ INSPECTIONS, TESTS, FILE SEARCH,. rA 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 flies 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 WiZliam R. Harvey~ Jr Telephone 345-7878 Address 13720 ])avls Rd. Anchorage, Ai< 99507 Date -6/18/86 Engineer's Seal ~ ~ ~.'~>' .,Z :'~;,e.''> ' Approved f or~ ¢/)bedrooms by e Approved ~ Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipaiity 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 purchas(~rs 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 72-025 (11/B4) iMUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTLCTION J U t 8 1986 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: LOT 12 BT,]( 5 RPERR?AD SU~nDZVISION .~,rO.2 T!2N R3W Well Classification 7[ ~ d J v i d u a ] If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) NO Date Completed Yield Total Depth,See Commer(lased to Static Water Level Casing Height Above Ground ] Electrical Wiring in Conduit (Y/N) Separanon Distances from Well: To Septic/Holding Tank on Lot see Comments Depm of Grouting Pump Set At f t, Sanitary Seal on Casing (Y/N) Y ¢ s y~,~ Depression Around Wellhead (Y/N) No 90-~, ft. ; On Adjoining Lots 129 ft. 124 ft, ; On Adjoining Lots !34 ft. To Nearest Public Sewer To Nearest Sewer Service Line on Lot N/A ;Date June 9; 1986 of well is 68 ft. from 1974 from s~m_page pit to well is 121.5 To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line 45.5 £t. Cleanout/Manhole /480 fi, Water Sample Collected by Win, R, Harvey, ~Tr Water Sam pie Test Results Satisfactory Comments Well Yield- 9,893 GPD. De~pth SEPTIC/HOLDING TANK DATA Date installed July Standpipes (Y/N) -Yo $ Air-tight Caps (Y/N) Depression over Tank (Y/N) No Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) N / A Separation Distances from Septic/Holding Tank: To Water-Supply Well ~¢9fl, % fi-, To Property Line 55 ft. To Water Main/Service Line ~/A Course N/A ]971 Size 1000/].200 No. of Compartments _1. Yes Foundation Cleanout (Y/N) Yes Date Last Pumped 6/9/86 ;for ~/A Temporary Holding Tank Permit (Y/N) N/A To Building Foundation hq. % fh, To Disposal Field 52 f t. To Stream, Pond, Lake, or Major Drainage Comments Dis*an-ce from seepage pit to se-ptic tank is 49 ft, ft. Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 125 Date Installed April 11, 1980 - Width of Field 2 ft Square Feet of Absorption Area .560 Depression over Field (Y/N) No Results of Last Adequacy Test Satis£actor¥ Separation Distance from Absorption Field: To Water-Supply Well 12 4 £ t To Building Foundation 90 £t Lot N/A To Water Main/Service Line N/A To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field 40 £b Depth of Field .5 £t , Gravel Bed Thickness 7 £t Standpipes Present (Y/N) Date of Last Adequacy Test Trench' Yes 6/7/86 To Property Line 12 ft To Existing or Abandoned System on ; On Adjoining Lots 57 ft To Cutbank (if present) N/A N/A 90 ft D. LIFT STATION N/A Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/FI) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Gycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Ratin~Against HAA .Request ** I certify that I h,a,ve checke~, verified,\or conformed to all MOA and HAA guidelines in effect on the date Company (/ MOA No. Page 2 of 2 ~¢,,~ R. Her D A~'F~ F~'~CEIVED INSPECTION AppOINTMENTS TIME TIME DATE DATE INSPECTOR INSPECTOR TIME DATE I NSPEC~r(~R MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHOP, AC-':'~ DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTION DEPT. OF ~. ~ ,, & 825 L Street - Anchorage, Alaska 99501 ENVII~Oi'.:,,L,', .[ ~, , LC'¢tON ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing. 1, PROPERTY OWNER MAILING ADDRESS /C' ~ PROPERTY RESIDEN~ (~f different from above) PHONE / PHONE PHONE 2. BUYER ~IAI LING ADD,F~SS 3, LENDING INSTITUTION. i -'7 '~-~.~ MAILING ADDRESS 4, "EALTgR/A~NT MAILING ADDRESS PHONE PHONE 5. LEG/~L DESCRIPTION STREET LOCATION ' 6. ~YPE OF R~SlD~NOE NUMBER OF~EDROOMS ~ 8no ~' Four -~ SINGLE FAMILY ~ Two ~ Five MULTIPLE FAMILY ~ Three ~ Six [] Other 7, WATER §UPPLY INDIVIDUAL*----, ~ COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled Since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM '~ INDIVIDUAL/ON,SITE** PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY 1~ INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER '[~}INDIV~DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER -f~EISeptic Tank or [] Holding Tank Size: 19A~L'~). If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line } Nearest Lot Line WELL TO: I Absorption Area to nearest Lot Line 5. COMMENTS ~ APPROVED FOR 4 BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY 72-010 (Rev. 6/79)