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T15N R1W SEC 9 LT 88 N2
T15N RIW Sec 9 Lot 88 N2 #051-104-39 Municipality of Anchorage On -Site Water and Wastewater Program • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP151148 PID Number: 051-104-39 Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade Name: RODNEY & JANICE KLEPZIG ABSORPTION FIELD ® Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Address 20533 White Birch Road, Chugiak, AK 99567 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 1.2 GPD/SF 10 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 4.93 Ft. Gravel depth beneath pipe 5.07 Ft. Subdivision Block Lot 88 N2 Fill added above original grade Varies -.25 to 0.82 Ft. Gravel length 50 Ft. Township Range Section 15N 1 W 9 Gravel width 2 Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Lift Station Tank Line 507 Ftp 2 10 Ft. Well 100+ 100'+ 100'+ NA NA TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer ANCHORAGE TANK Capacity 1 1250 Gal. Surface Water 100'+ 100'+ 100'+ NA Material STEEL Number of compartments 2 Lot Line 51+ 10'+ 5'+ NA NA Foundation 5'+ 10'+ 5'+ NA LIFT STATION Manufacturer Capacity Gal. Curtain Drain NA *50'+ NA NA Remarks *None known. Existing crib & tank Pump on level at in. Pump off level atHigh in. water alarm at in. decommissioned in place per code. S.T. insulated Pump make and model Electrical Inspections performed by PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Installer Northern Excavation Dralnfield 3034 CO/MT 3034 Inspector ARCTERRA BENCHMARK (Assumed elevation) 100 ft Inspection 1n6/18/15 6/18/15 Location and description 2"" s" 6/18/15 4" 6/18/15 Bottom of siding COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engin Aw OF AJ\\ Conditional Approval: Date j ` 49TH C KENNETH N. -.2 /fl 7118 ATO. AW t Approved Date Approved \ P�a,esstorM' Aw ear's Stam Inspection Report_9-1-12.doc AS -BUILT SYSTEM DETAILS/SITE PLAN Permit ❑SP151148 T15N R1W SEC 9 LOT 88 N2 PID# 051-104-39 M Z 0 o N O. °R z EXISTING�� z 0 4 -BR - 16.0• o GR 0 3E TH15-1 FCO BBM G 0 CO INSTALLED N 50 -GAL SEPTIC TANK 0 SPUTTE M F I E CO — H CO 0 76.5' N89'56'2_ E 0.13' SCALE- = 30' A -C=41' w99,85 99,8 101.6 B -C=14' MONITOR UH s 29 ]9 °'s"'a" FINAL GRADE 101.80 ` 100,9 A-D=37'rL IB -D=12' „d DISMHN rnTERv A -E=37' 1250 GAL B -E=25' $N SEPTIC 96A596.05 A -F=32' pO TANK SEWER ROCK UT B -F=22' TRENCH 1 I A -G=14' 97,11 97,11 90.98 90,98 _L I B -G=16' 25 MDMTDR TOE yqT A -H=33' 100.8 FINAL GRADE 100.7 B -H=32 SCALE NTS rn>r A -I=31' B -I=30' A -J=12' 96,0 96,05 B -J=31' SEWER ROCK `TRENCH 2 I C-90-5-8->90,98 84,48 mM M �F `�\ 25 SCALE, NTS 03 AW PREPARED F❑Rl ` C E n Aor RODNEY KLEPZIG ti �yR i\i� £ 20533 WHITE BIRCH ROAD o * .49 TH * Chuglak, AK 99567 907-854-9815 a 5 o I� HE M. S / FIELD BOOKS COMPUTED: w y CE -711 �� / BOUNDARY: DRAWN: BMW Z srMNcx cMEcxEa KMD gym^ ../�• . AssmLr JLS DATE: 7/7/15 �,-- \ FESSIi=� DM. FIM- GRID: NW1358 9�<FACIO j`_ ADAD FlLE: OO JOB Na: 15-140 SFR, 'TING g136 On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP151148 Tax Code Number: 05110439000 Work Type: Septic Upgrade Permit Effective Dates: June 09, 2015 to June 08, 2016 Design Engineer: ARC TERRA CONSULTING INC Subdivision: T15N R1W SEC 9 Site Legal Address: T15N R1W SEC 9 LT 88 N2 GA358 Owner/Address: KLEPZIG RODNEY C & JANICE L 20533 WHITE BIRCH ROAD CHUGIAK AK 995676048 Site Mailing Address: 20533 WHITE BIRCH RD, Chugiak This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank Lot Size in Sq Ft: 54450 Total Bedrooms: 4 N Privy N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By MUNICIPALITY OF ANCHORAGE Community Development Department Ph?Fax, q 4 Development Services Division On -Site Water & Wastewater Program�.S•iHI ON-SITE SEWER/WELL PERMIT APPLICATIONN U 4 2015 Parcel I.D. 051-104-39 Property owner(s) RODNEY & JANICE KLEPZIG Day phone Mailing address 20533 WHITE BIRCH ROAD, CHUGIAK, AK 99567 Site address 20533 WHITE BIRCH ROAD, CHUGIAK, AK 99567 Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) T1 5N R1 W SEC 9 LOT 88 N2 Lot Size 54450 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field �] Initial F] Single Family (SF) Septic Tank Upgrade (w/wo ADU) 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. Permit/Rush Fees: 61,A — i-N1-'iV Waiver Fees: Date of Payment: 512 -bs' CL+a,, Date of Payment: Receipt Number: 0 3 iD Receipt Number: Permit No. 05e/511W Waiver No. Permit App_9-1-12.doc May 27, 2015 CONSULTING, INC 212 E. 51" Ave, Anchorage, AK. 99503 Office (907) 868-3791, Fax (907) 868-3793 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: Upgrade Sewer Permit — T15N R1W SEC 9 LOT 88 N2 It has been determined that the absorption field of the subject property is saturated. Subsequently, the owner has requested we proceed forward to obtain a septic permit to upgrade the septic system. The existing system will be completely decommissioned. The general slope of this lot is from east to west at a grade of approximately 1-37o over the septic area. On May 19, 2015 a testhole was performed to investigate soils and groundwater. The results of this test are attached for your review. The proposed upgrade will serve the existing 4 -bedroom single-family residence. We propose to install a pressurized shallow trench. Groundwater was not encountered at excavation or at monitoring. The property and adjacent lots are served by private water. There is no surface water within 100' of the proposed system and there are no known curtain drains within 50'. We do not expect there to be any adverse effect on adjacent lots by the development of this system. If you have any questions, please contact me at 868- 3791 / FAX 868-3793. Respectfully submitted, ArcTerra Consulting, Inc. Kenneth M. Duffu Attachments: On -Site Sewer Application Wastewater Absorption System Details/Site Plan Soils Log/ Percolation Test 20441 PTARMIGAN BLVD • EAGLE RIVER, AK 99577-8736 • PH (907) 868-3791 • FAX (907) 868-3793 (WELL & WASTEWATER DISP❑SAL SYSTEM T15N R1W SEC 9 LOT 88 N2 3`d ' '10k.) ke.;;es Kp �� i I MBxM TINN (r MK & ORM) / aPlw e � FVA6 PR❑PEFTY LINES WELL RADII & EASEMENTS PRI❑R TO C❑NSTRUCTI❑N ND PUBLIC WELLS WITHIN 200' OF PROPOSED SYSTEM. NO PRIVATE WELLS WITHIN 200' OF PROPOSED SYSTEM EXCEPT AS NOTED. NO SEPTIC SYSTEMS WITHIN ROW OF PROPOSED WELL EXCEPT AS NOTED. OF AL4 �t, * 9 TH* �� KBNNE `1 CE -711J04 W ��e SSIO � mmaH DETAILS/SITE PLA 9 H Ca m 02 w- 951 Scale+ 1'= 50' DESIGN DETAILS PAGE 1 OF 2 4 BDRM X 150 GPD = 600 GPD 600 GPD/1.2 GPD PER SQ. FT. = 500 SQ. FT (500 / 2 x (5' GRAVEL) = 50 FT. TRENCH USE 2 TRENCHES - 25' (L) X 2' (W) X 5' (ED) Total depth of system Is 10' max from origlnal grade. Total depth of gravel below distribution pipe Is 5' NOTES1 1. INSTALL 1250 GAL & INSULATE TANK IF <4' COVER. 2. INSULATE TRENCHES WITH 2' HD BURIAL FOAM IF < 3' OF FILL. MIN. 2' FILL WITH INSULATION, )3' COVER NO INSUL REQ, 3. CONTRACTOR WILL ENSURE MINIMUM 2% SLOPE INTO SEPTIC TANK. 4. CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT WELLS, SEPTICS EASEMENTS, PROPERTY LINES, ETC... PREPARED FOR, RODNEY KLEPZIG 20533 WHITE BIRCH ROAD Chuglak, AK 99567 907-854-9815 FIELD BOOKS BOUNDARY. BOUNI sTAXINQ STAKIP ASBUILT: JLS Dw nLE: ADHD Fly` FILE COMPUTED: DRAWN: BMW CHEmED: KMD DATE' 5/27/1 GRID. NW135E " No.: 15-140 WASTEWATER DISP❑SAL SYSTEM DETAILS T15N R1W SEC 9 LOT 88 N2 DECOMMISSION EXISTING SEPTIC (TANK & CRIB) INSTALL NEW 1250—GAL SEPTIC TANK & FCO N89`56'2 FLAG PROPERTY LINES 4 WELL RADII & EASEMENTS PRI❑R TO CONSTRUCTION %�� OF ALS I 1 CE -77 IB �f a 04 AWr st PREPARED FOR, RODNEY KLEPZIG 20533 WHITE BIRCH ROAD Chugiak, AK 99567 907-854-9815 FIELD BOOKS camRum: Sou"' 13OUNDARY DRAM: BMW 9TMINQ STAKING MEmm KMD A:suiLT: JLS DATE: 5/27/15 DM FILE GRID: N W1358 ACAD RLE FILE '8 R0•' 15-140 0 SCQLel 1'= 20' PAGE 2 OF 2 Z"2RULTING � 6 'j' AK.99577- ,. QsRCTERRq ARCTERRA ~ CONSULTING, INC 212 E. 51"Ave, Anchorage, AK. 99503 „Office (907) 868-3791, Fax (907) 868-3793 SOILS PERCOLATION TEST Performed for: Rodney Klepzig Date Performed: 05 19 15 Project: T15N R1W SEC 9 LOT 88 N2 TEST HOLE # Depth 17- Org/OL SP/GP/gm mod dense, trace of silt, w/ cobbles to 1' B.O.H. - mosit 18 - HOLE PRE-SOAKED 19- PRIOR TO TEST 20 - *QAC TH ' Ill Irv4 \Rot7:^ssto�r� � \`ter TH 15-1 SEE ATTACHED SITE PLAN FOR HOLE LOCATION Was Ground water encountered? NO What depth? NA Depth to water after monitoring? NO Date? 5/26/2015 Reading Date Gross Time Net Time Depth of Water Net Drop 1 5/19/15 1:00 6" - 2 1:10 10 min 12/16" 5 4/16" 3 * 1:11 6" 4 1:21 10 min 14/16" 5 2/16" 5 * 1:22 6" - 6 1:32 10 min 16/16" 5 0/16" 7 * 1:33 6" - 8 1:43 10 min 15/16" 5 1/16" 9 * 1:44 6" - 10 1:54 10 min 15/16" 5 1/16" 11 * 1:55 6" - 12 2:05 1 10 min I" 5 0/16" * Water Added Percolation Rate 2 (min/in) Pere Hole Diameter 6" Test Run Between 5 feet and 6 feet I, Kenneth M. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in effect on this date. QPUE 8Gi • Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 sA CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-104-39 Expiration Date: 1. GENERAL INFORMATION Complete legal description T15N R1 W SEC 9 LOT 88 N2 Location (site address) 20533 WHITE BIRCH ROAD, CHUGIAK, AK 99567 Current Property owner(s) RODNEY & JANICE KLEPZIG Day phone Mailing address Real Estate Agent 20533 WHITE BIRCH ROAD, CHUGIAK, AK 99567 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ WaiverNariance request for: COSA to be released to the engineer, unless Day phone TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank ❑ Community ❑ Public Sewer ❑ Date: 10-W-15 v - COSA Fee $ o•2k�6� Waiver Fee $ Date of Payment 01-I1'15� Receipt Number 62013 COSA# 05c.15162-5 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. Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 8/25115 Engineer's Comments: This investigation was completed in compliance with AVEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the - evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen tett;; OFAL \ encroachments, deficiencies or discrepancies exist. 9s�� j* 49TI{ y _ 6. DSD SIGNATURE 1111" " A xENINE1' j System #1 Approved for bedrooms. 7116 System #2 Approved for bedrooms. ,,D; o�1(�G �i`EJ3lpt`� � Disapproved. Conditional approval for bedrooms, with the following stipulations Afi71-C r-" MW =` t PROGRAM �� , By: ,eAl Ilial Certificate Date: a S The Municipality Anchorage vN�'ment Services Di vision'(13SDJtW es 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 blue sh et_10-1012.dw If more than 1 septic system is on the lot: COSA Checklist # _of _ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: T15N R1W SEC 9 LOT 88 N2 Parcel ID: 051-10439 A. WELL DATA Well type PRVT If A, B, or C provide PWSID # _ Well Log (YIN) Y Date completed 717/1975 Sanitary seal (YIN) Y Wires properly protected (YIN) Y Total depth 205 ft. Cased to 200 ft. (33' Pert. -waiver) Casing height (above ground) 12 in. FROM WELL LOG AT INSPECTION Date of test 7/7/1975 511912015 Static water level 30 ft. 30 ft. Well production 5 g.p.m. 2.6 g.p.m. WATER SAMPLE RESULTS Coliform NEG colonies/100 mL Nitrate 35.1 mg/L Arsenic: ND ug/L Date of sample: 8131115 Collected by: ARCTERRA B. SEPTICIHOLDING TANK DATA Tank Type/Material SEPTIC I STEEL Date installed 6118/2015 Tank size 1250 gal. Number of Compartments 2 Cleanouts (YIN) Y . Foundation cleanout (YIN) Y Depression over tank (YIN) N High water alarm (YIN) N Date of pumping NA -NEW TANK Pumper C. ABSORPTION FIELD DATA Date installed 06118/15 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 System type DEEP TRENCH Length 50 ft. Width 2 ft. Gravel below pipe 5.07 ft. Total depth 10 ft. 5ff. absorption area 507 ft2 Monitoring tube Y Depression overfield N Date of adequacy test NA- NEW SYSTEM Results (Pass/Fall) For 4 rbedrooms Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in. Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at _ in. Datum Size in gallons "Pump off' level at _ in. Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 1004 Public sewer main 75'+ Sewer /septic service line 254 Animal containment areas 50'+ SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank 100'+ Manurelanimal excrete storage areas 100'+ Building foundation 5'+ Property line 51+ Absorption field 5'+ Water main 101+ Water service line 101+ Surface water 1004 Wells on adjacent lots 1001+ ABSORPTION FIELD ON LOT TO: Property line 104 Building foundation 104 Water main 10'+ Water Service line 104 Surfacewater 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain 50'+ (NONE KNOWN) Welts on adjacent lots 1004 F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that t 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. , Engineer's Printed Name KENNETH M. DUFFUS Date 8/25/2015 COSA canary sheet 2-6-15.doc . OP AZ /14C7jTx� .+ P xENNEM M. DUFM tF6 in. Municipality of Anchorage Oe%partme�nt went p P.O. Box 196650 •4700 Elmore Road y Anchorage. Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997 hftp://www.muni.org/Onsite. Development Services Division Onsite Water and Wastewater Program *** VARIANCE/WAIVER REVIEW **** Waiver* OSV151136 COSA#:OSC161625 Permit#: PID#: 051404-39 Legal Description: T18N, R1W, See 9. tot 88 N2 Engineer: Ar¢Terra Applicant: Rodney and Janice Klemia Your request to waive the requirement for 100% Bentonite grout be used in the subject property's well for the purpose of removing any cross -connection between a mown high nitrate aquifer and other deeper aquifers is approved. ❑ The affected adjacent .property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of non -objection have been received from the owner(s) of the affected - adjacent property. �. Adjacent properties are not affected by this waiver. Waiver is Granted: X Waiver is not Granted.- Date: ranted:Date: Johh Approved by: Same of Reviewer •...........•............ ...... ..... •i• a...b•..... •.....tl Waiver Not Submitted With COSA or Permit Engineer: /drc— /errA Legal: V51,j %fit 1 W '7ec q L g,ak Z Waiver Requested: G1( pe pMMl�iS Ak Distance: StetJe6i-9 er fA try -'w, Itittr C6,4,e [ /0/1)(5- Rush? ojl,(5` Rush? Yes No Waiver Fee: 0 Z! .5 Rush Fee: Date of Payment: /6 Receipt Number: a nmoo' —0 C) Waiver Number: GVl5 f la (a MOA Employee Reviewing Submittal Gi On Site Water and Wastewater\FormsUient Forms\Waiver not Sub With.doc tARR A CTER q , RC 1m ERRA CONSULTING, INC 56.?"y 777. ' R 212 E. 51"Ave, Anchorage, AK. 99503 �u sNe`Office (907) 868-3791, Fax (907) 868-3793 ti OCT 0 Z�t5 October 2, 2015 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 RE: WELL RETROFIT WAIVER —T15N R1W SEC 9 LOT 88 N2 Per previous discussions and correspondence with your office, the referenced well has been retrofitted as described in the attached inspection report from 907 Water Well Services. We are therefore requesting a waiver for the use of sand below the bentonite. With 6 bags of bentonite placed in the bedrock borehole extending up above the bottom of the well casing there are no cross connections within the proposed portion of the well filled with sand. If you have any questions, please contact me at 868-3791 / FAX 868-3793. Respectfully submitted, ArcTerra Consulting, Inc. Kenneth M. Duffus, Attachments: Well Retrofit Report RESIDENTIAL S COMMERWAL WATER AND WELL SERVICES 3cbn N¢th¢H:an 6630 Safi&" A=e Rnrl.o+eye 907— pwgpgyp# 0 '$ 6e To whom this may concern, 10/01/2015 Work was performed by 907 Water Well Services at 20533 White Birch Rd (T15N R1W SEC 9 LT 88 N2) in accordance to the scope of work agreement from the Municipality of Anchorage Onsite Water & Waste Water. The well was found to have a high concentration of nitrates and an investigation was conducted finding that the well had perforations at 35ft downhole (providing the source of water for the well). During the camera inspection, descent was stopped by a torque arrestor downhole impeding the ability to make a definitive measurement and visual inspection of the total depth of the well. Through the request of the Municipality of Anchorage the well pipe and pump were removed from the well finding that the total depth of the well was 204ft with casing ending at 86ft and the pump being set just under the bottom of the casing. After inspection the Municipality requested that the well be sealed to prevent any aquifer cross connections, but still allow the well to be operational. The well was filled with washed sand from a depth of 204ft to a depth of 102ft. From a depth of 102ft, 6 bags of 3/4bentonite chips were applied to make a seal from inside the bedrock formation at 102ft to inside the casing at 81ft now being the total depth of the well. This well produces enough water to supply the home for normal usage as the perforations were the only source of water. The pump was then reinstalled and the well was pumped to clean suspended debris from the well. New Well Report Total Depth 81ft; SWI 28ft; pitless @ l lft; cased to 81'; casing stickup lft; Has proper sanitary seal with wires inside conduit; saw no breaks cracks or perforations beyond above mentioned perforations. Bottom of hole is uniformly sealed from any aquifer cross connections. Sincerely John Netherton 907-230-1868 ANCHORAGE RECORDING DISTRICT ASBUILT OF: N1/2 LOT 88 SEC 9 T15N R1W S.M. SURVEY CERTIFICATION: I, John L. Schuller, have 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 enchroachments exist other that noted. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. Under no circumstance should any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. 15-009 Y 2, 2015 1 1"=30' JLS I NW1358 1 150225 = FND ALUMINUM MONUMENT O = FND 518" REBAR ................... JOHN L SCHULLER. o LS -10408 o & 1831 Talkeetna Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax 907 Water Well Services 6630 E 8TH AVE ANCHORAGE, AK 99504 (907)230-1868 johnnie.nethertonl 702@gmaii.com INVOICE BILL TO Rodney Klepzig 20533 White Burch Rd Chigiak, Alaska 99567 INVOICE # 1121 DATE 09/22/2015 DUE DATE 09/22/2015 TERMS Due on receipt ACTIVITY QTY RATE AMOUNT I Services Well Camera Inspection at 20553 White Birch Rd, Chugiak, Alaska 99567 Results are as described below. Total Depth of Well U/K upon inspection due to torque arrestor obstructing decent at 83'. Cased to 83'+ Pitless & 11' Casing stick up 12" Encountered Perforations at 36-37' yielding a nominal amount of water. likely only viable source of water production in well. Saw no breaks or cracks down to 83' Well has hard piped conduit providing good protection for wires encased. Also has a sanitary seal in operable condition. S.W.L @ time of inspection was 28' 300.00 300.00 Unpaid balances are charged 1.5% interest per month. Payments are BALANCE DUE Q'300.00 accepted via Cash, Check, and credit card. Thank you! Any questions $ please call 907-230-1868 r�4 MUNICIPALITY OF ANCHORAGE • T DEPARTMENT OF HEALTH & HUMAN SERVICES M Division of Environmental Services M 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 l.D.# C,'�)t-NLLt-10� L 1. GENERAL INFORMATION Complete legal description N 1/2 Lot 88 HAA # 1,4 (:\ 9 � (-+y-1 01 '_1) T15N R1W Section 9 Location (site address or directions) MUNI Wh i to Rirr+h-Rnari Chugi ak Property owner john Adamson Day phone 688-3470 Lending agency Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site X 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 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 furtherverify 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 Eagle River Engineering Services Phone 694-5195 Address P.O. Box 773294, Eagle River, AK 99577 Engineer's signature Date ,$��9 a 6. DHHS SIGNATURE xx Approved for Three (t 3 )bedrooms. Disapproved. Conditional approval for 1 bedrooms, with the following stipulations: Additional Comments Note • The well for this property meets existing State and Municipal Codes. There are nitrates present. It is suggogted that a periodic testing he porfnrmed to inrure }he molls continued suitability. Nitrate concentration is 7.5 mg/1. EPA Date 8/18/92 a11TIC 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(Bev. 1/91( Back MOAN21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST 44 Legal Description: /V '17- 1-07 SF Parcel I.D. t`,' r fF .'...j` 7/5N 1-�/bU Scc y A. WELL DATA Well typey12/VAJ--4If A, B, or C, attach ADEC letter. ADEC water ystem number Log present (Y/N) yZ3_ %� �� Date completed 7 Driller �- Total depth Z05' Cased to 6/2 04J7' Casing height 2 ,nC Sanitary seal (Y/N) yE 5 Wires properly protected (Y/N) Y Date of test Static water level Well flow Pump level FROM WELL LOG 5.0 g.p.m. MelvdAdly SEPARATION DISTANCES FROM WELL TO: Septic/hok4p@ tank on lot /2U' AT INSPECTION Nitrate// ,- Other bacteria Cleanouts (Y/N) c- 1 Collected by: zo Z Z/1 y y t - S J r g,p� m T n z / tv rn n i i!? o p m On adjacent lots /DD ' z Absorption field on lot On adjacent lots /OC% Public sewer main N� 9 Public sewer manhole/cleanout /v/m f Sewer service line- Petroleum tank Nom 4^, ,.re. t' +as'' WATER SAMPLE RESULTS: Coliform ,�� Nitrate// ,- Other bacteria Cleanouts (Y/N) Date of sample: 13/�9 Z Collected by: /2�/VboycG B. SEPTIC/HOLDING TANK DATA Date installed /97S Tank size 000 Compartments u^ K -J Cleanouts (Y/N) yc' 5 Foundation cleanout (Y/N) NO Depression (Y/N) ND High water alarm (Y/N) N/.a Alarm tested (Y/N) Date of pumping /D.? 1h Pumper r SEPARATION DISTANCES FROM SEPTIC/H9bBING TANK TO: i Well(s)onlot /20 On adjacent lots 0/00'/D CO- Foundation - To property line 70 Absorption field S' ES7 Watercaaia/service line Surface water/drainage /AlI1A 72026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DIST Well on D. ABSORPTION FIELD DATA — Manufacturer Manhole/Access(Y/N) _ ump off' level at Cycles tested LIFT STATION TO: On adjacent lots Surface water Date installed 19'75 Soil rating S i System type pa: Length U/J/U,1OWI-1 WidthUNKN01VAI Gravel thickness �c " Total depth yy " Total absorption area __ %r,r> ,r* 657- Cleanouts present (Y/N) Y&- S / Depression over field (Y/N) NO Date of adequacy test 0 2:Z 9Z Results (pass/fail) P,4 SS for l / 3 1 77,19CC- bedrooms Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD T 145 90 / ( bVAlv4,� Well on lot //0 On adjacent lots Property line 2 To building foundation /9 To existing or abandoned system on lot /y�A f / On adjacent lots -11,30' Cutbank NIA Water raa+elserviceline- Surface water /VIZA Driveway, parking/vehicle storage area 210 1 Curtain drain A�114 E. ENGINEER'S CERTIFICATION 1 certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature ✓'p��` '_ t Engineer's Name ��`"°' �" � r<' s,✓ � Date HAA Fee $ 1' � Date of Payment _� -%Z-C� -Z- Receipt Number 2 n 41 C 3Z/ 70 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 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 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) N 1/2, LOT 88: T15N, R1W. Section 9 Location (address or directions) WHITE: BIRCH ROAD, 3rd HOUSE nN LEFT, pETERS caEFK, AK (b) Applicant Name .TOHN ADAMSON Telephone: Home 688-4470 Business 276-4919 Applicant Address P.O. BOX_ 670863, CMTCTAK, ALASKA 99567 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builderEX; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution CITY MORTGAGE, Telephone 563-0700 Address 405 W �6t-h AITRMIR ANC.NQRAGF. ALASKA ArMN- I(tj N MARTTm (e) Real Estate Company and Agent n/a Address Telephone (f) Mail the HAA to the following address: PICKUP BY EAGLE RIVER ENGINEERING SERVICES 2. TYPE OF RESIDENCE Single -Family 130( Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well 13jx Community ❑ Public ❑ Note: If comm unity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite Ek 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. Pagel of 2 72-025 (1t,sa) 5. ENGINEERING FIRM PROVIDII NSPECTIONS, TESTS, FILE SEARCH, D, . 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, with approval of request of waivers. Name of Firm EAGLE RIVER IN INEERINC SERVICES Telephone —694-5195 Address P.O. BOX 773294 EAGLE RIVER ALASKA 99577 Date MARCH 31, 1987 J Vx's .�. �f .a9tP�✓ � �ir i.O�Y`•Y 9BO.n. Y' .. OY In Louis A. ate( ine6rr i J,'oo 066736` 6. DHEP APPROVAL Approved for A"zo bedrooms by , A• %y/�++� Date sl./3—$ � Approved ✓ Disapproved Conditional 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 72-025 (1 1/84) AUTY OF MUNOI ENTAL. SERVNCES DIV1S ON CHOIAGE ENVIROIJM APR 21987 RECEIVED A. WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOw) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: N %z Lot 8 6- 7-15-,,V /CIW Sc C., % S,/''L If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) y Date Completed 7Z �Z 7S Yield S GPI+ Total Depth ° 5 Cased to 31J r" * (Depth of Grouting vj4 Static Water Level ?S-' 6a4� z ., of r. Pump Set At y -lee' ' Casing Height Above Ground 2 ' Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) ! Depression Around Wellhead (Y/N) Y Separation Distances from Well: To Septic/Holding Tank on Lot /zG ; On Adjoining Lots 71 -/Go To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots To Nearest Public Sewer Line N14` To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot 125' Water Sample Collected by Eas It Date �Vlele7 Water Sample Test Results S< t- J "'ay Comments W4?v`t. 4f+�/.can.., �`°." 36?' c��f2 �.�o/cam �c. i.✓ �fL/87, B. SEPTIC/HOLDING TANK DATA Date Installed /5 7 S Size 1aZW 6w/ No. of Compartments Standpipes (Y/N) 11 Air -tight Caps (Y/N) % Foundation Cleanout (Y/N) Depression over Tank (Y/N) W Date Last Pumped Pumping/Maintenance Contract on File (Y/N) /0 ; for _'4 Holding Tank High -Water Alarm (Y/N) 'v�`� Temporary Holding Tank Permit (Y/N) Al Separation Distances from Septic/Holding Tank: To Water -Supply Well To Building Foundation /' i To Property Line To Disposal Field To Water Main/Service Line r7u ' To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11/64) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 5.S lleor Type of System Design S"eei�� X771 Date Installed /J 2.5 Length of Field uNtiN Width of Field Depth of Field / Gravel Bed Thickness Square Feet of Absorption Area esf Depression over Field (Y/N) Results of Last Adequacy Test Standpipes Present(Y/N) ss `¢ est, Date of Last Adequacy Test S -e -- 1 /*: Lf ZS -.,677. /2 /-e ArdF3— Separation Distance from Absorption Field: To Water -Supply Well To Building Foundation % 7 Lot /Wk To Water Main/Service Line 1121 To Stream/Pond/Lake/or Major Drainage Course To Property Line ?( ; On Adjoining Lots .11/GrJ 1 To Existing or Abandoned System on - Te / To Cutbank (if present) Nle. To Driveway, Parking Area, or Vehicle Storage Area �2, Comments u vd wig( SLr fc 7-e'7' L, le e e �4 e w.✓ �eeFr e� ems( /7/C,/.& rvel.Q_ !.r YO. ct/r1A tee- wau.e _fir op/.ocO - �f�7 �ff7 D. LIFT STATION i //. Date Installed Size in Gallons "Pump On" Level at — High Water Alarm Level at Tested for Electrical Codes (Y/N) _ Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I have ecked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. c Signed Date Company Fic .l, MOA No. 57 2 G S Receipt No. o` _ Oy ( ^ 0 C) Date of Payment `s^ ifl A s� 111 $ © r's Seal 10 Amount: G 6�Ab-0D Eagle River Engineering Services P. 0. Box 773294 Page 2 of 2 Eagle River, AK 99577 694.5195 72-626 (11/84) Louis A. Butora CE -6736 Municipwity of Anchorage April 13, 1987 P.O. L X 196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNO WLES, MAYOR DEPARTMENT OF HEALTH & HUMAN SERVICES Lou Butera, P.E. Eagle River Engineering Services P.O. Box 773294 Eagle River, Alaska 99577 Subject: N 1/2, Lot 88, T15N, R1W, Section 9 Waiver Request WR87-026 Dear Mr. Butera: Your request for a waiver of the 100 foot separation distance between the seepage pit on the subject property and the well on the the S 1/2 of Lot 88 has been granted. This distance has been waived to 90 feet. The letter of non -objection from the owner of this property is on file with this department. This waiver is based partly on your assessment that the bedrock plane is sloping steeply away from the affected well. This waiver is valid for the existing seepage pit only. Upgrades or enlargements of the septic system are not covered by this waiver. Your request for a waiver of the forty foot casing depth requirement for the well serving the subject lot has also been granted. Sincerely, Stephen S. Morris civil Engineer On-site Services cc Gus Andress Manager, Water Quality and On-site Services EAGLE RIVER ENGINEERING SERVICES klijwk Lou Butera P.E. MUNICIPALITY OF.ANCHURAGE ENVIRONMENTAL SERVICES DIVISION P.O. Box 773294 Eagle River, Alaska 99577 Ann , , .. Telephone (907) 694-5195 RECEIVED March 30, 1987 Mr. Steven Morris Civil Engineer, On -Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, Alaska 99519 REF: N 1/2, Lot 88: T15N, R1W, Section 9 Dear Mr. Morris: On behalf of my client, Mr. John Adamson, I am requesting a Municipal determination of a Separation Distance Wavier request and a request for reduction in the minimum well depth of 401. The requested waivers are neighbors private well, to applicants leach field, distance of approximately 90,' and a minimum private well depth reduction to 38' below ground surface. The septic system was installed by the owner in 1975 as evidenced by attached receipts. The septic system was installed without proper documentation and therefore our request for approval has included a soil log as per Municipal letter dated October 31, 1986. The soil log shows a GW type soil to a depth of 16', with some large rock at 121- 14' depth. There is no evidence of water table to 16' depth and the hole was probed to 18' depth to determine the absence of bedrock. The septic tank has been pumped and probed to determine size and type as a steel, 1000 gallon capacity tank. The seepage pit was tested as adequate for three bedroom usage and the operating effluent level is at a 41 depth which demonstrates that there is an organic material buildup. The surface topography between the two wells and the septic system is basically level (< 5%), as shown on the attached profile. The bedrock plane is sloped sharply away from the neighbors well, toward the septic system in question. Morris: N 1/2, Lot 88 Continued Page 2 The well on the N 1/2 of Lot 88, was perforated in error at a level of 36'-38' depth. As the well is located in a local depression, 2' of fill material will be necessary to allow a drainage away from the well in all directions. This leaves us with a 38' depth to water intake. The water sample taken March 18, 1987, indicates a 0 coliform bacteria count. The area in question has a low population density with typical 1 1/4 acre - 2 1/2 acre lots. If there are any contact me at 694-5195. Sincerely, Lou Butera, P.E. LB:bls enclosures problems or concerns, please feel free to - i GI ��� TiSN ?<w o 9 I " f lrl ' 11 .� — rn !n FIN O �: O QI FI, (fl _ Z i - IjNi fn O _y f - f r1 -i X 11 .� FIN Z i - ';3; SOILS LOG MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION E7 PERCOLATION 825 L. Street, Anchorage, Alaska 99601 264-0720 TEST SOILS LOG — PERCOLATION TEST PERFORMED FOR: V�h^v L�r�4.-n ,r 0'r DATE PERFORMED: 3 Al/d' 7 LEGAL DESCRIPTION: A L u ;e 8- _ 7-/-s-,4/ /e /G(/ se G r 9 1 2 3 ` - p c 4- 5 5 c 6 01'0 J o' 7 O , o 9 a, p o'• 0 10 11 0• °, o 12 13 •`"` 14 "—v • L 15- 16— i 5 16 I T-1- So' 6A7v/C Sc,,,t 8' Gave/ GW SAA"D ff aiOAdEG or ttz 17 ........-r.' 0 :49TH §#. ♦.... .a......a�n.`e...i..• 19- oll 20 Louis A. 6utera �' Com•". CE -6736 ����� s'�•.......•`.��m {�! FOFESSV33-' V COMMENTS ver E WAS GROUND WATER S ENCOUNTERED? NO L O P IF YES, AT WHAT E DEPTH? LAN Reading Date Gross Time Net Time Depth to Water Net Drop /Y/ I PERCOLATION RATE LS h'�^' �.."�-!� (minutes/inch) TEST RUN BETWEEN l FT AND FT I .S✓i/ em.7' �"f PERFORMED BY: Fanta plrnr w.g-aaaripg Servlees CERTIFIED BY: //. DATE: 31 a "IJ 7 P. 0. Box 773294 Eagle River, AK 99577 72-008 (6/79) 694-5195 EAGLE RIV` ENGINEERING SER�.,:ES INC. P. 0. Box 773294 EAGLE RIVER, ALASKA 99577 Phone 694.5195 J 0 B Al Lc VR SHEET NO. iv 'c iw sec 4 OF CALCULATED BY L �•�T^'T�� DATE 3/Z"2"". 7 •eeu, Z//1/S7 CHECKED BY DATE_ PERF N/.(.�.. TO E paA� SSS ceGtiwG. '. VA00 mwIN IM.. Do.. Mrn 01,71. SCALE uy-r 2. r '., N T4 _ a a� ° 4 ti o L 3 W 3 _ W ! H PERF N/.(.�.. TO E paA� SSS ceGtiwG. '. VA00 mwIN IM.. Do.. Mrn 01,71. E2 G r I 7 m NOTES: I. RECORD INFp RM ATION QASED uFt:, OLM ` T WFASHIP PLAT OF TISN KIW S.M. AK. DATED MAY 15 1155. ANY INFORMATtoN ON PLATS RECOR[3ED PRIOR ` �c( OF Q .�` TO OR AFTER THE 6EFORFJ-lENT10NED PLAT IS NOT SHOWtl- • . �aS�„ f l ...j NTS BET THIS SURVEY. •,'9 -` - D. (M) MEASURED INFORMATIONAL CALLS. • •• 49T1, •••S -- 4. �. (R) RECORD II-1FORMFS{IONAL. GALLS. ... . � J`TFi;IE,cAcHA! TO THE ...iI.. ........ AREsr,•c-RVALID t OR - L0 t T Stonloy Sean o > / No. 7087-5 -�...- 4 m• .r R000v23iED D/4' REBAR s •� / 9Fp•'•.•„,..� ///v� T. ® RHGOVER FJ7 AL4MINLIM ��O 1���OFfSSIONt-L ��4 p` CAP MONLIM64T. - - DATE RECEIVED INSPECTION APPOINTMENTS s�e- cl S vn •� TIME TIME -e TIME l. 1AIG DATE DATE _ m DATE SINGLE FAMILY 1 ) INSPECTOR INSPEC R INSPECT 7. WATER SUPPLY INDIVIDUAL* 205 r 'I V. ❑ COMMUNITY MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGC DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTErE`,,EEPT. OF K --AI, 1; 1 R 825 L Street -Anchorage, Alaska 99501 NMENTAL Ni:OILCTION ENVIRONMENTAL SANITATION DIVISION DEC, 8 1980 0* Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEOIIFFiF ff?rLS DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE E. Ar -)a or! fob -3 70 MAILING ADDRESS bbd qy14 -A C>lu I K, 995(a PROPERTY RESIDENT (If different from above)PHO E "?. L t T15 RI w Seal S. t>1h' to b',�ry, Rd 2. BUYER P O E MAILING ADDRESS 3. LENDING INSTITUTION c PHONE Nome. �� DERAL X L, A N7 1 5 MAILINGADDRESS Sa)S ID sfi. »flQ 9950 j 4. REALTOR/AGENT PHONE MAILINGADDRESS S. LEGAL DESCRIPTION N % Lot cbeb Tis zi W s�e- cl S vn STREET LOCATION Whl Ee-H Rel GhLn 1AIG 6. TYPE OF R SIDENCE NUMBER OF,BEDROOMS SINGLE FAMILY ❑ One ❑ Four ❑ Other \ ❑ MULTIPLE FAMILY ❑ Two ❑ Five Three ❑ six 7. WATER SUPPLY INDIVIDUAL* 205 r *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** I2%-4 YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLICUTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 10l'i0 jr! .. a/I uacl�/c.cw T-" -UJ-� 72-010 ( Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER of BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY El PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified ❑Septic Tank or ❑ Holding Tank Size: If Tank is homemade give dimensions: PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATI NO TYPE OFTANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Absorption Area to nearest Lot Line Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line 5. COMMENTS WL-APPROVEDFOR3 BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) dJ--DISAPPROVED DATE , . a_ -42)( BY �^ 72-010 ( Rev. 6/79)