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NOV 13 2018 Municipality of Anchorage NOV I
Community Development Department Page 1 of 2
On -Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP171087 PID Number: 018-191-24
❑ New ❑✓ Upgrade
Name:
BRIAN ANDERSON ABSORPTION FIELD
Address
❑ Deep Trenchhallow Trench ❑ Bed ❑ Mound
14040 SABINE ST ❑✓ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
3 0.8 GPD/S F 7.0 Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot
3.5 Ft. 3.5 Ft.
STRZELEWICZ
L13B Fill added above original grade Gravel length
Township Range Section
Ft. 61 Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCES 5.0 Ft. `_
Ft.
Tol Septic Absorption Holding I Sewer Total absorption area Number of trenches Dist. between trenches
From Tank Field Lift StationTank Line 305 Ft2 1 -
Ft.
Well111.9 134.7 N/A N/A 188.4 TANK El Septic ElS.T.E.P. ElHolding E:1Other
Manufacturer Capacity
Surface Water 100+ 100+ N/A N/A i Anchorage Tank 1000Ga1.
Material Number of compartments
Lot Line 40.0 23.3 N/A N/A Steel 2
NA
Foundation 20.9 40.1 N/A I N/A LIFT STATION
Manufacturer Capacity
Curtain Drain 50+ 50+ I N/A N/A Gal.
Remarks Pump on level at Pump off leve High water alarm at
in.1 in.
Pump make a odel Electrical Inspections performed by
PIPE MATERIAL House to tank Tank to 3034
Installer 3034 drainfield
FLINSTONE ENTERPRISES Drainfield 3034 CO/MT 3034
Inspector Pannone Engineering Services BENCHMARK (Assumed elevation) 240 ft
Inspection5c
dates: 1 6/9/17 2°d Location and description
6/9/17
3`' 5/15/18 4'" AT HOUSE POINT B
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp
.r•�`v�'t11
Conditional Approval: Date ��GF •ggSl�
teven PannoneOwl,
{ C ��81 z4,9�
Approved t o ¢��,`!� !' • ;.,..
pp Cn ���� Date / FD �',�•
l/ I d D I 1, �osoaA
Inspection Report_1-1-12.doc
DESIGN PARAMETLL--RS
PRIMARY SEPTIC SYSTEM w E)
NO. BEDROOM: 3(450 gpd)
PERC RATE: 10 MPI A
SOIL RATING: M GPD/SF
AREA ROD: 562.5 SF
REDUCTION FACTOR: 0.54 A
ADJ ABSORPTION AREA: 303.75 7�
SYS. TYPE: WIDE TRENCH 4,0'ED� r2 4 0] TRUE NORTH LE
MIN LENGTH: 61 .0 LF
TOTAL AREA: 305 SF
INSTALLED DRAIN FIELD
W1 CO&MT AT ENDS
4 C
FS 2
VACANT LPT |
/
�|
TANK INST LLED NE ~
\ ''
\
DCO
29.3
96.3
BEFORE & DCO AND-
3
r -`�/
C2
34.3
103.9
\ �
/
AFTER
11 1,9
.
' |
VACANT LPT |
/
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TANK INST LLED NE ~
\ ''
\
SEPTIC TANK WITH DC0
BEFORE & DCO AND-
3
r -`�/
/
/ | QUAN�CS TRU-FL0 FS
'
\ �
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AFTER
11 1,9
.
' |
UJ Z FILTER FABRIC
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OG. FG.
WELL/
u :�E OG. FG. DRAIN ROCK 6" ABOVE PIPE INV
|
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L UiU Esrn'
240
_ ��
235 4" 0 DRAIN PIPE
--
— -----�
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VACANT LPT |
\
\ \
\ ''
\
U
u-
UJ Z FILTER FABRIC
C) uj
OG. FG.
u :�E OG. FG. DRAIN ROCK 6" ABOVE PIPE INV
240
235 4" 0 DRAIN PIPE
Eu,
H-1
u
OR
ORGANIC
7
1000 9 SEPTIC
u
-L
IFSilty
TANK
7E 3.5' SEWER ROCK
GRAY
1
2_31.5
SAND
PROFILE
SCALE:NTS
SM
COBBLES
DRY
5/12/17
DATE
RECORD DRAWINIGS
WI S
PAMONE ENG SVC, LLC
P.O. BOX 102954 ANCHORAGE,
Dot e ---
1/7/19
AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
Scale
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2D R A ACP
EPLAN
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ANDERSON BRIAN L DEC OF TRUST
even nnoR
018-191-24
140 40 SABINE ST
CE 8149
SITE
ANCHORAGE, AK 99516
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ospi 1087
Sheet
TEST *oL[ z
. =OR ORGANIC
M !GRAY
I Silty SAND &
ICOBBLES
12
ao*
DATE PERFORMED: l5MAY2Ol7
NO GROUNDWATER
SOILS'LOG — pERC01LA7lON TEST
SLOPE
READING 1 DATE TER 1 1 SOIL TEST R
NET TWE LE EL NET DROP
3 TEST RUN BETWEEN 5FTAND6FT,
ST
RECORD DRAWING
WING
PANNONE ENG WC, LLc
Dote
P.O. BOX 102954 ANCHORAGE, AK 99510
1/7/2019
PHONE (907) 272-8218 FAX (907) 272— 11
Scole
NTS
:D:R�A:W:�N'�JRL��
ANDERSON BRIAN L DEC OF TRUST
nope
018-191-2
SOILS LOGS
14040 SABINE ST
ANCHORAGE, AK 99516
CE 8149
PERMIT NO.
OSP171087
Sheet
J,,
' "
- _
" '` MUNICIPALITY OF ANCHORAGE
On-Site Water&Wastewater Program
PO Box 196650 4700 Elmore Road
-41
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
/ http://www.muni.org/onsite �.
cpartt
4M1.c0-10R>VE
On-Site Wastewater Disposal System Permit 6-7-1 7 (�
7q4 7 60(i-
Permit Number: OSP171087 Effective Date: 5/30/2017
Work Type: Septic Upgrade Expiration Date: 5/30/2018
Tax Code Number: 01819124000
Site Legal Address: STRZELEWICZ LT 13B G:3034
Site Mailing Address: 14040 SABINE ST, Anchorage
Owner: ANDERSON BRIAN L DEC OF TRUST Lot Size in Sq Ft: 44212
Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 3
This permit is for the construction of:
El 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
Special Provisions: The entire proposed disposal field is not within a 30 foot radius of an existing percolation
test. A percolation test hole is to be completed prior to construction of the septic field. If the results require a
design change, construction of the system shall stop pending On-site review and approval. Please submit
stamped and signed results with the inspection report/record drawings.
Received By: ', i' I Date: s i 7—
Issued By: �,(�� c !' Date: 30 .2o ( 7
1\„„,
•
-) Municipality of Anchorage
intuitt
P.O. Box 196650 • 4700 Elmore Road
Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax(907) 343-7997
http:llwww.muni.org/Onsite
Development Services Division
On-Site Water and Wastewater Program
**** VARIANCE/WAIVER REVIEW ****
Waiver#: OSV171037 COSA#: Permit#: OSP171087
PID#: 018-191-24
Legal Description: Strzelewicz Lot 13B
Engineer: Pannone Engineering Services
Applicant: Anderson Brian L Dec of Trust
Your request for a waiver of the requirement that the absorption field be installed parallel to the
contour lines of the slope has been approved. See engineer's letter and profile drawing for
waiver justifications.
This waiver approval applies to the proposed absorption field only. Any future upgrade to the
on-site wastewater disposal system will require all code requirements be met or another approval
from this department.
❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this
waiver.
n Notarized letter(s) of nonobjection have been received from the owner(s) of the affected
adjacent property.
VI Adjacent properties are not affected by this waiver.
Waiver is Granted: X Waiver is not Granted:
Date: 5/2q/ 20 I I Approved by: �' C
Name of Reviewer
**** VARIANCE/WAIVER REVIEW ****
MUNICIPALITY OF ANCHORAGE
:(
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On-Site Water& Wastewater Program
ON-SITE SEWERNVELL PERMIT APPLICATION
Parcel I.D. 018-191-24
Property owner(s) ANDERSON BRIAN L DEC OF TRUST Day phone
Mailing address 14040 SABINE ST, ANCHORAGE AK 99516
Site address 14040 SABINE ST, ANCHORAGE AK 99516
Legal description (Sub'd., Block & Lot) STRZELEWICZ L13B
Legal description (Township, Range & Section)
Lot Size 44,212 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(El all that apply)
Absorption Field ❑X Initial ❑ Single Family (SF) ❑X
(w/wo ADU)
Septic Tank ❑X Upgrade ❑ Duplex (D) ❑
Holding Tank ❑ Renewal ❑
Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR:
lo,o U^! of ksi `0 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: 5(,A Waiver Fees: 41'215
Date of Payment: _ 61 I /II 1 Date of Payment: 5/2q/7
Receipt Number: 0,7216,_o�6,_ Receipt Number: Ddb 5 66
Permit No. oS Q 11 Oeg1 Waiver No. OS V 1 1 lb S rl
Permit App_ .: ::.,c
Pannone Engineering Services tic
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail:steve@panengak.com
May 9, 2017
Subject: STRZELEWICZ L13B
Septic System Permit Request
Design Narrative
This is a design narrative for a permit to install an upgrade septic system to be issued for this property.
The proposed system will serve an existing three (3) bedroom house. Currently the lot is developed. The
system will utilize a new 1000g septic tank and a drain field. This lot and the surrounding developed lots
are served by private wells. There are no wells within 100' of the proposed septic system.
1. Soils. One test hole was performed in the vicinity of this system by PES in May 2017, and groundwater
was monitored for at least seven days. Ground water was not observed to a depth of 13.0' below the
surface in the test hole monitor tube in May of 2017. Bedrock was not encountered in the test hole to
13.0'. Based on the results of the percolation tests and overall soils appearance; an application rate of
0.8 gallons/day/square was used for a conventional system in the area of the test hole.
2. Soil Absorption System Design.
a. See Sheet 1 of the design package.
3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field.
The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage
ditches.
4. Topography: The existing topography on the lot generally slopes from east to west, with a slope
of approximately 5-8% in the area of the drain field. There are no steep slopes within 50' of the proposed
drain field. The proposed drain field will maintain 50' separation all steep slopes.
5. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification that
the review is complete and that there are no further comments is received from MoA On-Site
Department, the note will be removed and "Issued for Construction" drawings will be issued.
The proposed installation will not affect the future development of this or the surrounding lots.
Mailing: P.O. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
Pannone Engineering Services uc
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail:steve@panengak.com
May 22, 2017
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road
P 0 Box 196650
Anchorage, Alaska 99519-6650
Subject: STRZELEWICZ L13B
Slope Orientation Waiver Request
Ladies and Gentlemen:
We request a slope orientation waiver for the absorption field. The field will need to be installed
perpendicular to the assumed contour lines due to existing features on the lot. The depicted contours do
not provide an accurate representation of the slopes. By installing the field per the plan separation from
the bottom of the test hole will be maintained. Granting this waiver is not likely to affect the health and
safety of this lot or the surrounding lots now or in the future.
If you have any questions or concerns, please contact me at 907.272.8218.
Sincerely,
coP� OF q .�0
i • 4• H\is. A
IV
•
iota... Steven R.Pannone 4=
. jC�Oi
PISIFESS
Steven R. Pannone, P.E.
Owner/Civil Engineer
Mailing: P.O. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
DESIGN PARAMETERS N
_PRIMARY SEPTIC SYSTEM
NO. BEDROOM: 3(450 gpd) - r
TANK SIZE: 1000g -, - - - \ 1 ,,*
PERC RATE: 10 MPI L J ��+,. , •. • ** * .,�
SOIL RATING: 0.8 GPD/SF WELL „r'
AREA RQD: 562.5 SF --
REDUCTION
� ��
REDUCTION FACTOR: 0.54 r - - - "',� \
ADJ ABSORPTION AREA: 303.75
TRU iNOR1Ii SCALE 1r-5Q'
SYS. TYPE: WIDE TRENCH 4.0'ED \ Ie. ! I
MIN LENGTH: 61.0 LF 1 �- - \
i ! I
USE: `s-ci r < \ / I
61.OLFx5.O'Wx3.5' E.D., 7.0' TD AF,-ic, 13A N
l \ J 1
TOTAL AREA: 305 SF 9
112351 f 240 192.2 240
I \ / 176.0 / /
61 LFx5.0'Wx3.5'E.D. 7.0'T.D.
CO&MT AT ENDS P �_ w I - �I1 1
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12301, t 1 OF CONSTRUCTION N 1 1 �� \ I ; /14
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R&R 1000G SEPTIC \ \ \ \
\ TANK WITH DCO BEFORE l I l l
/� II I I & DCO AND QUANTICS 13B 157.5 3BR l \ I
I �I I TRU-FLO FS AFTER(P) 118.35FD 1 240 +�
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12.0- 13.0 SECTION A-A BOH
- 13.0 BOH NO GROUNDWATER
NO GROUNDWATER �7 �T SVC ,PANNONE ENG SVC, LLCDate
FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 P�G.• ;�,g� 05/22/17
PHONE (907) 272-8218 FAX (907) 272-8211 Scale
*,• ll 1" = 50'
• •• •4 ••• P.I.D. NO
STRZELEWICZ L13B ai, ,,,, 018-191-24
ANDERSON BRIAN L DEC OF TRUST / 41even -. -annoae PERMIT NO.
DRAWN JRLCE 8149 }
14040 SABINE ST �R'• .. osP171o87
SITE PLAN ANCHORAGE, AK 99516 4kiiiiiii. Sheet
1 OF 3
TEST HOLE 1 SOILS LOG — PERCOLATION TEST
SLOPE SI 7 PLAN
OR ORGANIC
1 13A
2 —
/ 235 240 P
►1
3
4 )___
5 "Plik
6
X TEST f
7 HOLE f/ ill
SM GRAY
8 Silty SAND &
COBBLES
9
10 OF CONSTRUCTION
I
11
12
1V
13
BOH
DATE PERFORMED: 02MAY2017 WAS GROUND WATER SLOPE
NO GROUNDWATER ENCOUNTERED? N
TH 1
IF YES, AT WHAT
DEPTH? -NA-' X
DEPTH TO WATER AFTER
MONITORING? - DRY -
DATE: O8MAY2017
12MAY2017
CLOCK WATER RATE SOIL TEST RESULTS/ANALYSIS
READING DATE TIME NET TIME LEVEL NET DROP (MPI) • PERCOLATION RATE 10(min/Inch)
READING
(Hydrologic Soils Group: HSG A)
1 02MAY17 1005 5.900" • PERC HOLE DIAMETER 6"
2 1035 30 MIN 9.561" 3.661" 8.2" • TEST RUN BETWEEN 5 FT AND 6 FT.
3 1036 5.900" • TEST RUN FOR OVER AN HOUR. LAST
• THREE READINGS PROVIDED.
4 1106 30 MIN 9.045" 3.145" 9.5"
5 1107 5.900"
6 1137 30 MIN 9.052" 3.152" 9.5"
COMMENTS:Test hole excavated by JR's SEPTIC.
PERFORMED BY:Joseph Lawendowski. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE
AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST.
.•
NOTES: PANNONE ENGENGSVC. LLC
.
1 ��. Date05/15/17
F OR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 9951110• •
PHONE (907) 272-8218 FAX (907) 272-8211 d ••. .4_•'.Scale
*:'�• `
lig . NTS
41101, ' P.I.D. NO
- STRZELEWICZ L13B • 1. -
191-24
ANDERSON BRIAN L DEC OF TRUST •.M n �• PERMIT NO.
DRAWN JRL 14040 SABINE ST r ;.;.• CE 8149 OSP171087
SOILS LOGS ANCHORAGE, AK 99516 '' Sheet
2 OF 3
I
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF
ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF
ON—SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55.
2. SCOPE OF WORK: INSTALL NEW 1000g SEPTIC TANK, AND SOIL ABSORPTION SYSTEM.
3. GROUNDWATER WAS NOT ENCOUNTERED TO A DEPTH OF 13 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL
TEST HOLE. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 13 FEET BELOW
EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY.
4. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION AND SEPTIC
LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED
SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK.
5. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.O.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED.
6. THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES.
7. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER PRIOR TO START OF WORK. ALL SURVEYING
AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER.
6. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE
CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN.
9. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED—LINE AS—BUILT DRAWINGS TO THE
ENGINEER. THE RED—LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND
TANK ELEVATIONS.
10. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION,
TOP OF PIPE WITH CLEAN—OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING.
11. THE CONTRACTOR PROVIDED DATA (UPON WHICH THIS RECORD DRAWING IS BASED) APPEARS TO REPRESENT THE
PROJECT AS CONSTRUCTED. THIS DATA IN CONJUNCTION WITH THE PERIODIC FIELD OBSERVATIONS BY THE ENGINEER
(OR HIS DESIGNEE) AS REQUIRED BY AMC 15.65 DOES NOT GUARANTEE THAT THERE ARE NO HIDDEN DEFECTS BY THE
CONTRACTOR_
12. THE CONTRACTOR SHALL SIGN THE FOLLOWING:
I CERTIFY THAT ALL WORK WAS PERFORMED IN ACCORDANCE WITH THE APPEND PERMIT, AND ANY AND ALL CHANGE
ORDERS, AND THAT THE AS—BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS
CONSTRUCTED.
CONTRACTOR:
BY: . TITLE:
DATE:
NOTES: PANNONE ENG �T LLC Dote
PANNONE �7 Y C, 05/15/17
FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 !'�'••'"'"'•.' -
PHONE (907) 272-8218 FAX (907) 272-8211 4.. •• 1 'y Scale
'� NTS
V&A P.I.D. NO
STRZELEWICZ L13B ;: ••• •• •• - •-i91-24
DRAWN JRL ANDERSON BRIAN L DEC OF TRUST ' .; �° cE 8149 ° PERMIT NO.
14040 SABINE ST OSP171087
DESIGN NOTES ANCHORAGE, AK 99516 I :� Sheet
� ��\�� 3 OF 3
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LOT 13A
N 89°56'12" W 299.54'
— — — — — — — — — — — — —
x
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SHED � i
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x
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!, 10' UTILITY EASEMENT
N 89°56'24" W
00oI
GRAVEL DRIVE
2%
64.8
28.3
N
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x 2.1'
U)—+ 6.0'
Z �
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2B.3
-----------+-------7—--6
— — — — — — — —— -
- — — — — — — — — — — — — — — — — — — —
NOTES; 1, ENCROACHMENT AGREEMENT, DATED JUNE 9, 1990, EXECUTED BY
CHUGACH ELECTRIC ASSOCIATION, INC. AND DANIEL AND JULIET SOHN, INCLUDING
TERMS AND CONDITIONS CONTAINED THEREIN, RECORDED JULY 9, 1990, BOOK 2050 PAGE 760
IAS—BUILT OF: LEGAL DESCRIPTION:
299.58'
ORDERED BY. BRIAN ANDERSON
T
O
O
O
4-
N)
W
M
01
30'
30'
SURVEY CERTIFICATION: LANTECH has conducted a physical survey of this
property as shown on this drawing and that the improvements situated thereon
are within the property lines and no encroachments exist other than noted.
S U g EXCLUSION NOTE: It is the owners' responsibility to determine the existence
of any easements, covenants, or restrictions which do not appear on the
recorded subdivision plat. NOTE: Under no circumstances should any data
hereon be used for construction or for establishing property lines.
LEGEND: SET FND
5/8"RB W/CAP (i 5/8" RB
3.25" AL.MON. MONUMENT
HUB & TACK ❑
FENCE— —X— X —
OVERHANG—
WOOD DECKS—
CONCRETE—
ASPHALT—
GRAVEL—
SEPTIC
ECKS—
CONCRETE—
ASPHALT—GRAVEL—SEPTIC STANDPIPES— O
WATER WELL— w
e ~/ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAl_ PROTECTION
ENVIRONMENI'AL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone .2.64-4720
ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELl_ INSPECTION REPORT
P,ONE
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Iw.,, J Absorp,~..re~ Dwelling PERMIT NO,
~ .DISTANCE TO: JO~)~ ~ ~
~<~ Manufacturer G~~ Materia~.~ No. of compartments
~ ~ Liq. capacity in gallons Inside length Width Liquid depth
~DOC) IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
O Well Foundation .~q Nearest lot line P~MI NO
~= DISTANCE TO: JO0 ~~/ J O0 %
~ ~ ~ No. of lines I Leng01 of each line Total length of lines Trench wid,h gistance between lines
~ 6~ 6~ ~0 inches
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ glass Depth Driller Distance to lot llne PERMIT NO,
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
O!
o~ ~e~ so;~S
72-013 (Rev. 3/78)
PERMIT NO.
MIUN I C: I I~ '::iL I T"T" ,":_iF FII-,tL-:H, RF"i"]E
' DEPRRTMENT L'~,~/HERLTH RND ENVIRONMENTRL P~iTECTION
e,,,.~ 'L' STREET., RNcHORRGE, WK. 99501
L~ELL R~gTM Or-$--S I TE SERES: F'ER£'I I T
RPPLICRNT G. MERRILL DBR RK BLDG
LOCRTION
LEGRL LigB STRZELEWICZ
TYPE OF SOIL RBSORPTION SYSTEM
MRXIMUM NUMBER OF BEDROOMS = g
' A 9950?
SRR BOX 4t~-E RNCHOER~E g45-6127
LOT SIZE 999999 SQLiRRE FEET
DRR I NFI ELD ~
THE REQUIRED SIZE OF THE SOIL RBSORF'TION -~T'_TEM :
DEPTH= 4 LEr-~GTH= I 48 GRR%tEL DEPTH= 2
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND RND THE BOTTOM OF THE E×CRVRTION (IN FEET).
THE TREr-~CH L,JIDTH IS 5. 000 FEET.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE
8ND THE BOTTOM OF THE EXCRVRTION (IN FEET).
F:EQLIIRED SEF'TIC TR~K SIZE= 1888 GRLLO~S
PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPBRTMENT DURING THE
INSTRLLRTION INSPECTIONS OF RNY WELLS RDJRCENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THRT THE WELL WILL SERVE.
TP~O (2) I ~SPECTIO~S RRE REQLIIRED
BRCKFILLING OF BNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTRNCE BETWEEN 8 NELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS
i00 FEET FOR R PRIVRTE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET 8ND
TO R COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
RVRILRBLE TO INSURE PROPER INSTRLLRTION.
PEF.'.M I T E.~-(F' I RES DECEI~18ER .7,1., 1982
I CERTIFY THRT
1: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH BY THE MUNICIPFILITY OF RNCHORRGE.
2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
_~: I UNDER_$,liRND THRT THE ON-SITE SEWER SYSTEM MR'T' REQUIRE ~LRRGEMENT IF THE~ ~ ~,
RESIDENCE ~ REMODELED TO INCLUDE MORE~~EDROOMS.~ ~ { ~~ ~
~ --~--~ -~------~ .......... ~ .
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
2
3
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
PERFORMED BY:
WAS GROUND WATER SL
ENCOUNTERED? Y~0 0
P
E
IF YES, AT WHAT
DEPTH?
3,5",1' hals,
DATEPE"FORMED: "7
SLOPE SITE PLAN
TEST RUN BETWEEN
PERCOLATION RATE ~1~ ~'~, ~__ [minutes/inch)
~i~', FTAND ~ FT
t DATE:
CERTIFIED BY:
72-008 (6/79)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
SLOPE SITE PLAN
1
2
~3
~_~4
§
6
7-
.._~8 -
9-
J
't ,
10-
11
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
13
14
15
17
18
19-
20-
Gross Net Depth to Net
Reading Date Time Time Water Drop
V
PERCOLATION RATE c~o~- (minutes/inch)
, , TESTRUN BETWEEN ~..~L~ FTANE~
~V~-W DRILLING, Inc. ~'/
P.O. Box4-1224 · 1310C International Airport Road
(907) 274-4611
ANCHORAGE, ALASKA 99509
DRILLING LOG
Well Owner : :., ' i. :.. Use o/~ Well
Location (address of: To~vnship, Range, Section, if known; or distance main road
Size of casing_ ':''~ Depth of Hole
Static water 1eve! i:;oft. (abbve)
Screen ( ); Perforated (
I.:,, , feet Cased to · - feet
(below) land surface. Finish of well (check one)
).
Describe screen or perforation
Well pumping test at ' ;~ gallons per of drawdown from static level
Date of completion. '-%?-;4 ; ~ ~, 'l
(minute) for ' hours with ~;"~ '
WELL LOG
Depth in feet £rom
ground surface Give details of formations penetrated, size of material, color and hardness
~ TO-
_ A TO i >
i: TO !J ~
; TO '! t 0
~ v? fro_ i 3
':~:'.TO_ ~.
TO_
TO
TO.
_ _TO.
__.TO
.TO_
__ .TO
open end (. : );
ft.
'-"
3--CONTRACTOR
MAN ERV
DEPARTMENT OF H~LTH & HU S ICES~
D v s on of Env mnmental Se~ices
On-S te Se~ices Section
CERTIFICATE OF H~LTH:AUTHORI~
~APPROVAL FOR A SINGLE FAMIL~ DWELLING
Lot ~g; S~z~z-S~b~v~o~
5. STATEMENT/OF NSPECTION BY ENG!NEER
i. As certified bY my seal affixed hereto and'as of the ValidatiOn date show~ below, I verify that my
' investigati0'n of this Health AUthorityApproval~application shows that the on-site water supply
:and/or wastewater diSPosal system s sa~ei functi0nalland adequate for the number of bedrooms
and type of structure indicated herein. I ~Urtl~ei'~rify~that based on the information obtained from
the Municipality of Anchorage files and from'my inves.tLgation and inspection, the on-site water
supply and/or wastewater.disp0sai sys. tem? i,n c0mp.!ianc? wi!h all Municipal and State codes,
. ordinances, and regulations in effect on the date of this inspection.
' S&SF'NGINEERiNG~ * ~'' Phone. ~'~z/.~.~
......... Name of Firm iTG3,i ~=gle, ~iver Laop Koed No, ;zaP4
Eagle River, Alaska ~$77 / ,: · . ':. · :
Engineer's signature : Date '::~7
--,~.~ :~.. ,,t ~F .... '~ '%-/. ~-/-~' ~ '-7./ ....
" Date ' ' .......
~ C~e~:'l ~ HHS) issues Health Authon~/
~ased on v Unoh' the'representations g yen ~:paragraph 5 above by an ~ndependent
H'eg )f Alaska; The DHHS does this as a cou~esy to purchasers of homes
/~e~.taih fe~l~n~ state requirem~ntS.EmPl°yees of DHHs do not
or aha yze data before a cert f cate s ssued The Mumc~pal ty of Anchorage ~s not
. .",~.,~,, , . .......... · .... edr'S~vOrk." ?,.', :=~',~ !, ~ ~' : :~'~ · '
e for erro~,or omissions In the professional englrl · : ;~.,: .. : ; .
Legal Description:
Health Authority Approval Checklist /~t'C*[ r~70
S r ,~ 'z.t,l. g ~ i c 'z- ParcelI.D.: O/ ~ ~ l "l ,I - ;)"t'il
A. WELL DATA
Well type
Log present
Total depth
Sauitary seal
IfA, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ / 3' 'f' /fi' ~
Cased to ] 6 { Casing height (above ground)_
Wires properly protected
ImROM WELL LOG AT INSPECTION
Dateoftest ~ / )- S- tl s; Z ~
Static water level /0 0 ' ~ 6'
Well production I g- g.p.m. /, 7 g.p.m.
WATER S/4IVlPLE RESULTS:
Coliform
Date of sample:
Nitrate
O, [ Other bacteria
Collected by: g~r-c,Z Rt¥.t/<
SEPTIC/I ....... TANK DATA
Date installed ~/ll/g2 Tanksize /ooo NumberofCompamnents '~ Cleanouts~/N)_
Foundation cleanout ~ ~ ~.' '"' a Depression (Y/~ ~'~ o High water alarm (Y/~$) ~' ~
Date'bfPum~5i~g.?(o /"/ [ et $~.L Pumper 4- -F /'/~,n~L
A SOaffi0 mi D DAXA '
Dat~,i~sialled i ~- 22 ' Soilrating (g.p.d./ft2o ~-'~--o Systemtype
Lengtl:;,,. ~.c~ · Width ~ Gravel thickness below pipe 6'" Total depth ! 0
Effective absorptiofi area (a ~ O Monitoring Tube present(i~tN) Yfvj' Depression over field (Y/~ /~' O
Date ofadequacytest q /q t/q'S'- Results ~ail) P~ ,CJ For -L~ bedrooms
Fluid depth in absorption field before test (in.); ~q 9 :~ "haraedtately after ~6'-gal water added (in.): q [?
Fluid depth 5" Minutes later: 5~'q" (in.) Absorption rate = ") q ~- g.p.d.
Peroxide treatment (past 12 months) (Y~
% I=,~ 'reS>- o~
ffyes, give date
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycle~ te~
Size in gallons ~
"Pump on"~p off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/hc, ld~ng tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
; On adjacent lots
_; On adjacent lots
Public sewer inanhole/cleanout
Lift station
/oo
/O0 ~
SEPARATION DISTANCES FROM SEPTIC/}IOLDI~ TANK ON LOT TO:
Fouudation ~' ff'- Properly liue ~c-
Water main/service line /0 (4- Surface water/drainage /o
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Bnilding foundation lo !'P Water main/service liue )o
/
Snrface water / o o ','- Driveway, parking/vehicle storage area
Wells on adjacent lots / 0 0
Cnrtain drain ~ ,,,' ,t. k'~, o ~' a/
F. ENGINEER'S CERTIFICATION ~~~-~
I certify that I have determined thrufield inspections and review of Municipal ems are
Signature '/*~ ~. ~J~ ~:~~,L ,.~
Ellgineer s Name lC 0~,~ ~ ~. cO~ ~ [ no~t c. cow~u ], ~
- c
............................................................................................ ~_~ ........
HAA Fee $ ~, ~ Waiver Fee $
Date of Payment ~//~ff~ Date of Payment
Rev. 8/95 OSS: haa.wk.doc
ADEQUACY TEST FORM
CLIENT: ~l~ $0~
ROBERTC. COWAN, RE.
ROBERTA. SHAFER, EF,
SEWER&WATER
b~JN EXTENSION~
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
LEGAL DESCRIPTION: t-o ~- /3
# OF BEDROOMS: 3
TYPE OF ABSORPTION SYSTEM:
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-t211
OATE:
SEPTIC TANK/FIELD SEPERATION TO WELL: / e o/-+-
T?(,-, c,/4 SEPTIC TANK SIZE: I o o O
ABSORPTION FIELD DATA: Depi;ession over field (Y/~: ~' 0
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Driveway, parking/vehicle storage area:
Curtain drain:
Foundation:
SEPTIC DATA: Date of pumping:
Foundation cleanout (Y/N):
LIFT STATION: "PUMP ON" level at:
~r alarm level:
Pumper:
Depression (Y/N): ..
"~'e~e I at:
WELL INSPECTION
& FLOWTEST
SITE PLANS
0
ROAD DESIGN 0
SOILTEST
STflUCTUPJ~L &
IN$PECTIOhI~
TIME
/ ?,~
/0 '.0 ~/
METER GALLONS
READING ADDED
~/ ;;z. (TOTAL)
LIQUID LEVEL I'
o~ x,~¢ COMMENTS
S.T. M.T. M.T.
.RESULTS: ~FAIL:
EXPLANATION:
TESTED BY: /~ & (..'. .
THIS SYSTEM IS NOT GUARANTEED AGAINST SUBSEQUENT FAILURE
17034 NORTH EAGLE RIVER LOOP · SUiTE 204 · EAGLE RIVER. ALASKA 99577
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Location (address or directions)
1 4-0 X+o S
(b) Property owner
Mailing Address
(c) Lending Institution
Mailing Address
[4~ ~.L. ~ ~J ~ Telephone: (home)
Telephone
(d) Real Estate Company and Agent %',
Address '"'"~.
Telephone
(e) Mail the HAA to the following address: (or check here.~' if hold for pick UP.).
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ ' Number of bedrooms
3. WATER SUPPLY
Individual Well Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site~, 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 (Rev. 7/88) Page 1 of 2
5. 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, and regulations in effect on the date of this inspection.
NameofFirm ~__..t,,J,~ ~tc-,~-L.._ ~',~,~\~JL~--l~/?,_.Telephone ~ ~'~ O
Address ~ ~( ~C~ ~d~
Date ~/ /~
Engineer's Seal
Approved for ,_~ bedrooms by ~ . . Date ~/~,~-~'/
Approved ~ Disapproved Conditional
Terms of Conditional Approval
'f-'~,'J i[fl~
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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. 7/88) Back Page 2 of 2
A. WELL DATA
Well Classification [~' ~ v,,~
Well Log Present (Y/N) Y~'~< Date Completed
Total Depth //6~ ~. Cased to
Static Water Level (~4--"
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
To Nearest Sewer Service Line on Lot
Water Sample Collected by ~-~
Water Sample Test Results
Comments '/~/~ ~ ~
(~O MUNICIPALITY OF ANCHORAGE (MOA) Elealth Authority Approval (HAA)
[CIPALITY (~i.~GiI~. FEBRUARY 1984
NMENTAL SERVICES DIVI~.4744
MAY 1 5 1990 Legal Description: ~o'T /~ ~
RECEIVED
If A, B, C, D.E.C. Approved (Y/N)
~--Z~ ~ Yield /6~/~,~
Depth of Grouting ~/~
Pump Set At
~ Sanitary Seal on Casing (Y/N) ~
Y~ Depression Around Wellhead (Y/N) ~
/
; On Adjoining Lots
/
~ J Z.~ ; On Adjoining Lots '~ ~' O0
To Nearest Public Sewer Cleanout/Manhole /'J/
;Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~/3 l/~Z--Size
Standpipes (Y/N) YL~
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N),
Holding Tank High-Water Alarm (Y/N) /~//~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
( O CO No. of Compartments
Air-tight Caps (Y/N) "~'~ Foundation Cleanout.(Y/N)
~ 0 Date Last Pumped ~/i~'~/q(-)
~,,jO ;for
Temporary Holding Tank Permit (Y/N)
To Water-Supply Well
To Property Line
To Water Main/Service Line
To Building Foundation
To Disposal Field
To Stream, Pond, Lake or Major Drainage Course
Comments
72¢026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ¢~ -',~ ~.-- ~Z~
Width of Field ~
Square Feet of Absortion Area
Depression over Field (Y/N) /k.j O
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
~ [7~O/
To Water Main/Service Line '~ 1_ 00 /
Type of System Design
Length of Field ~i~ ~.~
Depth of Field ~ ~,~
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line '~ Z ~'-' /
To Existing/or Abandoned System on
; On Adjoining Lots '~ ~00
TO Cutback (if present) /..J'/,Z~
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)~.. ,~'~
Comments ,/~'~'"'
Dimensions
Manhole/Access (Y/N) ~--~-~'~
"Pump Off" Level at ~
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines~in effect o,n the date of this
inspection. "-¢// './] 0 '-- ~ :'""~ '~
Signed
Company /Z,~ t~?~,~.t.., L.-~--M~t~%¢/4' ~,,'C~
Date ~'/~/ ~O Seal
MOA No. ~ ~ ~. O ~ ~2 :$ 0
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) 8~ck
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
KNIEFEL ENGINEERING
8441 MILES COURT
ANCHORAGE, ALASKA 99504
(907)337-6560
HEALTH AUTHORITY RESULTS AND ANALYSIS
Date of Testing: April 27, 1990
Legal Description: Lot 13B, Strzelewicz Subd.
Street Address: 14040 Sabine
Number of Bedrooms: Three (3)
Results of Well Flow Test: Passed
Average Flow Rate -- > 6 gpm
Results of Laboratory Water Analysis: Passed
Coliform -- 0 colonies
Nitrate-N -- < 0.1 mg/1 (10 mg/1 allowable)
Testing Laboratory: Northern Testing Laboratory
Results of Septic System Adequacy Testing: Passed
Approva 1 s:
The water and sewer systems are approved for a home with three
bedrooms. 7q~e home was occupied at the time of testing. The
drain field was charged with 500 gallons of water in the far
field clean-out. The field level nor the septic tank float level
changed due to the input of the water. The well exceeded the
requirement for both HUD and MOA requirements. These test
results are based upon conditions present at the time of the
testing. The tests followed standard Municipality of AnchOrage
testing procedures,
APPLI~.',NT~, FILLS OUT UPPER HA~'~ ONLY
Address Zip Code
Lending Institution~/~. ~~Z~ ~51~~0 · Phone
Realty Co. & A~nt
Address ~ ~ff~ ZipCode
Legal Descript~n ~O~ /~ ~ ~
Type of ResJ~nce
Water Supply
~.[J For wells drilled prior to that date, give well depth (attach log if available);
Individual ' Year Indiv~ual Installed:
~Publ[c Utility When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time
Date Date Date Date
inspector Inspector Inspector Inspector~'~' -~"~ ~'~ ~.~ ~-
Field Notes: ~! /viUNICIPALITY OF ANCHORAGE
~, DFPT
ENVIROi ~M Jh; A.-[ ,O,EC/ION
[.i0V 8 1982
RECEIVED
(~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
~)--~ '~' WelltoTank / ~)O Septic Tank Size
~_,.;
~ ~
;ii o