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HomeMy WebLinkAboutTIMBERLUX #2 BLK H LT 10Timberlux #2
Block H
Lot 10
#018-271-45
UBMITTA
Municipality of AnchorageNOV kr 3
Community Development Department Page
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: OSP131215 PID Number: 018-271-45 ❑ New
ZU14
1
1 of 3
Upgrade
Name:
Francis & Joyce Bebey
ABSORPTION FIELD
❑ Deep Trench i
Other
Shallow Trench Bed ❑Mound
Address
4825 Hillandale Avenue
Phone
Number of Bedrooms
4
Soil Rating
4 GPD/SF
Total depth from original grade
2.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
- 1.5 Ft.
Gravel depth beneath pipe
0•5Ft.
Subdivision Block Lot
Timberlux #2 H 10
Fill added above original grade
1 Ft.
Gravel length
30.0 Ft.
Township Range ' Section
Gravel width
5.0Ft.
Beds: Number of Lines
N/A
Distance between lines
N/A Ft.
SEPARATION DISTANCES
To
From
Septic
Tank
Absorption
Field
Lift Station
Holding
Tank
Sewer
Line
Total absorption area
150 Ft:
Number of trenches
1
Dist. between trenches
N/AFt.
Well
113.7
129,1
113.7
N/A
93
TANK ■ Septic 0 S.T.E.P. • Holding • Other
Manufacturer
Anchorage Tank / Orenco
Capacity
1500031.
Surface Water
100+
100+
100+
N/A
NA
Material
STEEL
Number of compartments
2
Lot Line
44.2
26.1
41.3
N/A
Foundation
15.5
47.8
27.0
N/A
LIFT STATION
Manufacturer
Orenco
Capacity
250 GaI.
Curtain Drain
N/A
N/A
N/A
N/A
Remarks
Pump on level at
43 in.
Pump off level at
40 in.
High water alarm at
45 in.
Pump make and model -
P2005
Electrical Inspections performed by
Installer
Beeks Contracting
to
PIPE MATERIAL House to tank 3034 Tank drainfield3034
Drainfield 3034 CO/MT 3034
Inspector Pannone Engineering Services
BENCH MARK (Assumed elevation) 100ft
Inspection,
dates: 1 ' 12/16/13 2m 12/16/13
Location and description
Corner of house trim
3'" 12/22/13 a"
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Conditional Approval: Date
Engineer's Stamp
�OF
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Approved / Gam° . Ad Date _�7 �S
Inspection Report_1-1-1 T.doc
M
M
DRAIN FIELD (6)
30LF x 5'W x 2.5'ED
IN FAILURE RE -USE AS RESERVE
WELL (6) I_
,
117.6
LOT VACANT
NO WELLS OR SEPTICS
REMOVED
IB IOCYC LE
LS2
•
•
10'UUUTILITY EASEMENT
TH-2
TOBBEN SPURKLAND
NEW DRAIN FIELD
/ 30LF x 5'W x 0.5'ED x 2.0'TD
NEW INSULATED 1500g S.T.E.P. TANK
WITH HOLD DOWNS, AX20 POD, -SAND
AUXILIARY PUMP VAULT
— N � 1►
' 4" HOPE SERVICE LINE (P)
3=0.0030 MIN
\ ,. \
/ \ o.
/ c�
A
SEPTIC AREA (6) T�
\\,
11 3 71 0
SEPTIC AREA (6)
74/
A AA
NOTES:
PLAN
PANNONE ENG SVC, LLC
P.O. BOX 100217 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
TIMBERLUX #2, BLOCK H, LOT 10
FRANCIS & JOYCE BEBEY
4825 HILLANDALE AVENUE
ANCHORAGE, AK 99516
---7D-r,4"‘‘
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/5*C�t,
Steven R. Pannone j
h -v.... CE 8149 .A2j
ftl sr' •':,:
PRoFEsso ---
l\\\��.�---
Date
11/3/2014
Scale
r'=50'
P.I.D. NO
'018-271-45
PERMIT NO.
0SP131215
Sheet
2 OF 3
A
B
C
T1
17.4
26.3
-
LS1
25.0
33.0
-
LS2
28.2
36.0
-
M1
61.6
-
103.7
M2
51.9
-
79.3
M
M
DRAIN FIELD (6)
30LF x 5'W x 2.5'ED
IN FAILURE RE -USE AS RESERVE
WELL (6) I_
,
117.6
LOT VACANT
NO WELLS OR SEPTICS
REMOVED
IB IOCYC LE
LS2
•
•
10'UUUTILITY EASEMENT
TH-2
TOBBEN SPURKLAND
NEW DRAIN FIELD
/ 30LF x 5'W x 0.5'ED x 2.0'TD
NEW INSULATED 1500g S.T.E.P. TANK
WITH HOLD DOWNS, AX20 POD, -SAND
AUXILIARY PUMP VAULT
— N � 1►
' 4" HOPE SERVICE LINE (P)
3=0.0030 MIN
\ ,. \
/ \ o.
/ c�
A
SEPTIC AREA (6) T�
\\,
11 3 71 0
SEPTIC AREA (6)
74/
A AA
NOTES:
PLAN
PANNONE ENG SVC, LLC
P.O. BOX 100217 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
TIMBERLUX #2, BLOCK H, LOT 10
FRANCIS & JOYCE BEBEY
4825 HILLANDALE AVENUE
ANCHORAGE, AK 99516
---7D-r,4"‘‘
..�.Pig...y' • 7
;*:49 A\ .*
,
/5*C�t,
Steven R. Pannone j
h -v.... CE 8149 .A2j
ftl sr' •':,:
PRoFEsso ---
l\\\��.�---
Date
11/3/2014
Scale
r'=50'
P.I.D. NO
'018-271-45
PERMIT NO.
0SP131215
Sheet
2 OF 3
SPECIAL PROVISIONS TO SPECIFICATIONS
ALL CONSTRUCTION WAS 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.
3. SCOPE OF WORK: INSTALLED NEW 1500g S.T.E.P. TANK WITH AX20 POD AND AUX. PUMP VAULT. INSTALLED SOIL
ABSORPTION SYSTEM.
4. GROUNDWATER WAS ENCOUNTERED AT A DEPTH OF 7 FEET BELOW EXISTING GRADE A5 EVIDENCED BY THE SOIL TEST
HOLE. AN APPARENT WATER TABLE WAS NOT OBSERVED IN ANY OE THE EXCAVATIONS LESS THAN 7 FEET BELOW
EXISTING GRADE.
TH
SPUR KLAN D-1995
CLEAN OUT
15.0
0
0
a
ML
LIFT STATION
a
W
94.0 1
1500 g S.T.E.P.
TANK (P)
98.2
/'-RIGID INSULATION
—FILTER FABRIC
�/ 134' 0 PERE PIPE W/
ROLES 18" O.C.
I
—DRAIN ROCK 6" ABOVE PIPE INV
9 2
50
91.2
9/11/95
SECTION
X FUME VAULT
INSULATED
(SEE ADVANTEX DETAIL)
LEGEND
WATER LINE/
WELL RADIUS
SS NEW SEPTIC
r.5
1 —96.7
031 —96.2
DRAIN ROCK
09 0
z
w
0 0
H
0w
0
a
r RIGID INSULATION
FILTER FABRIC
j-1 34" m PERF PIPE W/
34" e HOLES 18" 0.0.
/ ) FDRAIN�ROCK 6" ABOVE PIPE INV
99.2
98.2
PROFILE
DESIGN PARAMETERS
RESERVE SEPTIC SYSTEM
NO. BEDROOM: 4 (600 gpd)
TANK SIZE: 1500o S.T.E.P.
W/ AX20 POD & AUX PUMP VAULT
PERC RATE = 16-30 MPI
SOIL RATING: 4 GPD/SF
AREA ROD: 150 SF
SYS. TYPE: WIDE TRENCH
MIN LENGTH: 30 LF
USED:
30 LF X 5' WIDE, 0.5' E.D., 2.0' TD
TOTAL AREA: 150 SF
-s 7
96.2
DRAIN ROCK
ABBREVIATIONS
CU COPPER
DIP
TH
FC
T#
Cfi
M#
R.I.
DCO
DV
FS
BFG
00
FG
TS&V
DUCTILE IRON PIPE
TEST HOLE
FOUNDATION CLEAN OUT
TANK CLEAN OUT NO.
CLEAN OUT NO.
MONITOR TUBE NO.
RIGID INSULATION
DOUBLE CLEAN OUT
DIVERTER VALVE
FLOW SPLITTER
BELOW FINISH GRADE
ORIGINAL GRADE
FINISH GRADE
TOPSOIL & VEGETATE
NOTES
RECORD DRAWING
PANNONE ENG SVC, LLC
P.O. BOX 100217 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
DESIGN DETAILS
TIMBERLUX #2, BLOCK H, LOT 10
FRANCIS & JOYCE BEBEY
4825 HILLANDALE AVENUE
ANCHORAGE, AK 99516
*49TM � . • *• `li
Steven R. Pannone ,I+11
T101 �OFEfec. CE Bs,ON: �/
\\p���
Dote
11/3/2014
Scale
NTS
P.I.D. NO
018-271-45
PERMIT NO.
OSP131215
Sheet
3 OF 3
Engineer:
_egal Description:
Municipality of Anchorage
P.O Box 196550 4700 Elmore Road
Anchorage, Alaska 99519-6650 (907) 343-7904 Fax (907) 343-7997
htto://www.muntorgionsite
Planning and Development Services Department
On -Site Water and Wastewater Program
On -Site Sewer/Well Submittal Comment Sheet
PANNONE ENGINEERING SERVICE
TIMBERLUX #2 Blka-I Lt 10
12/24/2014
'ermit: OSP131215 Septic Completed By: J.Poet
2eportType: As Built Review
-he attached paperwork has been reviewed and is being returned for the following reasons:
Electrical Inspections performed by?
Q2 ra-t.,s&C trs�"4 5-tPc(2t cAc erg -cot -7
FF2aM--R)c&cYC(./3/ 7lO a-t&c'()-(cAC�SPUcZC4),--)
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: OSP131215
Tax Code Number: 01827145000
Work Type: Septic
Permit Effective Dates: August 15, 2013
to August 15, 2014
Design Engineer: PANNONE ENGINEERING SERVICE
Subdivision: TIMBERLUX #2
Site Legal Address: TIMBERLUX #2 BLK H LT 10 G:3136
Owner/Address:
BEBEY FRANCIS A & JOYCE
4825 HILLANDALE AVENUE ANCHORAGE AK 995164148
Site Mailing Address: 4825 HILLANDALE AVE, Anchorage
This permit is for the construction of:
Y Disposal Field Y Septic Tank N Holding Tank
Lot Size in Sq Ft: 50470
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 By:
Issued By:
MUNICIPALITY OF ANCHORAGE
Community Development Department
Development Services Division
On -Site Water & Wastewater Program
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 018-271-45
Property owner(s) Francis & Joyce Bebey
Day phone
Mailing address 4825 Hillandale Avenue, Anchorage, AK 99516
Site address 4825 Hllandale Avenue
Legal description (Sub'd., Block & Lot) Timberlux #2, Block H, Lot 10
Legal description (Township, Range & Section)
Lot Size 50,470 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN:
(® all that apply)
Absorption Field
Septic Tank
Holding Tank
Privy
Private Well
Water Storage
Initial
Upgrade
Renewal
TYPE OF DWELLING:
Single Family (SF) ❑X
(w/wo ADU)
Duplex (D) ❑
Multiple Dwellings ❑
(SF and/or D)
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.
(Si nature of property owner or authorized agent)
Permit/Rush Fees: 53D—
Date of Payment: 1 Ji81/
Receipt Number: c 33 Ct
Permit No. ns f 131 16
Permit App__-
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
Pannone Engineering Services ac
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail: steve@panengak.com
July 17, 2013
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
4700 S. Bragaw Street
P. 0. Box 196650
Anchorage, Alaska 99519
Subject: Timberlux #2, Block H, Lot 10
Septic System Upgrade Permit Request
Ladies and Gentlemen:
I am writing to request a permit to install a septic system be issued for this property. The proposed
systems will serve an existing four (4) bedroom house. Currently the lot is developed, and the existing field
will be re -used as a reserve. The existing Biocycle will be removed and a new 1500g S.T.E.P. tank with
AX20 Pod and Auxiliary Pump Vault will be installed. This lot is served by a private well that is over 100
feet from the existing and proposed system. The surrounding developed lots are also served by private
wells. There are no wells within 100 feet of this system.
1. Soils. One test hole was excavated in the area of this drain filed by Tobben Spurkland in September
of 1995, and groundwater was monitored at 7.0 feet below the surface. It is my opinion, based on the
results of the percolation tests and overall soils appearance; an application rate of 4.0 gallons/day/square
feet should be used for a CAT III wastewater system.
2. Soil Absorption System Design.
a. See Sheet 2 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 slopes from east to west at approximately 20%-25% in the
area of the proposed drain field. There are no steep slopes in the vicinity of the drain field.
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.
Mailing: P.O. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
Page 2 of 2
The proposed installation will not affect the future development of the surrounding or existing lots. There
are no wells or septic systems within 100 feet of the proposed septic location.
If you have any questions or concerns, please contact me at 272-8218.
Sincerely,
.15.17.1...4:: .Ay
diP l
'41
...0‘...0‘p ��yyTH �
•.m.:n.-fir •itliii,
\h •
•
■
E Steven R. Pannone F a
G9 no oun et222a
Steven R. Pannone, P.E.
Owner/Civil Engineer
Attachments
-Soils Log
-Septic System Design
Mailing: P.O. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor Ave, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
�
LOT VACANT
NO WELLS OR SEPTICS
i
REMOVE BIOCYCLE (E)
DRAINREL0(E)
3OLF x 5'W x 2.5'ED
|N�A|LURERE-USE ASRESERVE
,WELL (E)
/n_� -2
. x'\ ' T0DR[NSPURKU\ND
114.2
. •
„.„
NEW DRAIN FIELD
/J0LFx5'YYx0�5'[Dx28'TD
' �
`s‘
10' UTILITY EASEMENT
INSULATED 1500g .[E.P TANK
WITH HOLD DOWNS, AX2O POD, AND
AUXILIARY FUMP VAULT
/
'-`' \
! /
-_-- ` ,
4"HDPE SERVICE LINE (P)
5=0.0030 MIN
•
4 BR
HOUSE (E)
SEPTIC AREA (E)
`
\ \
\ \ � |
\
`
SEPTC AREA (E)
�
NOTES:
m
_``�
*/`
FOR CONSTRUCTION
PANNONE ENG SVC, LLC
P.0.BOX 1O0217 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
PLAN
TIMBERLUX #2, BLOCK H, LOT 10
FRANCIS Xc JOYCE BEBEY
4825 HILLANDALE AVENUE
ANCH0RAGE, AK 99516
`��r``|
���
..:7��^
m
sk t:An.?0. F:s.‘.07.Litirtnna:e
Date
8/9/2013
Scale
l^=so'
p/u.wo
018-271-45
PERMIT NO.
osp13l11u
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.
3. SCOPE OF WORK: INSTALL NEW 1500g S.T.E.P. TANK WITH AX20 POD AND AUX. PUMP VAULT. INSTALL SOIL
ABSORPTION SYSTEM.
4. GROUNDWATER WAS ENCOUNTERED AT A DEPTH OF 7 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL TEST
HOLE. IF AN APPARENT WATER TABLE I5 OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 7 FEET BELOW EXISTING
GRADE NOTIFY THE ENGINEER IMMEDIATELY.
w
zs
¢o
z
za
0W
Li -
OV
TH
SPURKLAND-1995
O
0
15.0
a
X
LIFT STATION
1500 g S.T.E.P.
TANK (P)
RIGID INSULATION
FILTER FABRIC
1 Ya" 0 PERF PIPE W/
14" 0 HOLES 15" 0.C.
DRAIN ROCK 6" ABOVE PIPE IW
alas 2AP.15 .r
2.0 ___
I-5
DRAIN ROCK
50
9- /11/95
SECTION
PUMP VAULT
INSULATED
(SEE ADVANTEX DETAIL)
LEGEND
W WATER LINE/
WELL RADIUS
SS NEW SEPTIC
w
CO
r z
w
K
O
z6
0
RIGID INSULATION
FILTER FABRIC
14"0 PERF PIPE W/
J4" 0 HOLES 18" 0.C.
DRAIN ROCK 6" ABOVE PIPE INV
PROFILE
DESIGN PARAMETERS
RESERVE SEPTIC SYSTEM
NO. BEDROOM: 4 (600 gpd)
TANK SIZE: 1500g S.T.E.P.
W/ AX20 POD & AUX PUMP VAULT
PERC RATE = 16-30 MPI
SOIL RATING: 4 GPD/SF
AREA RQD: 150 SF
SYS. TYPE: WIDE TRENCH
MIN LENGTH: 30 LF
USED:
30 LF X 5' WIDE, 0.5' E.D., 2.0' TD
TOTAL AREA: 150 SF
DRAIN ROCK
ABBREVIATIONS
CU
DIP
TH
FC
T#
C#
M#
R.I.
DCO
DV
FS
BFG
OG
FG
Ts&V
COPPER
DUCTILE IRON PIPE
TEST HOLE
FOUNDATION CLEAN OUT
TANK CLEAN OUT NO.
CLEAN OUT NO.
MONITOR TUBE NO.
RIGID INSULATION
DOUBLE CLEAN OUT
DIVERTER VALVE
FLOW SPLITTER
BELOW FINISH GRADE
ORIGINAL GRADE
FINISH GRADE
TOPSOIL & VEGETATE
NOTES:
FOR CONSTRUCTION
PANNONE ENG SVC, LLC
P.O. BOX 100217 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
DESIGN DETAILS
TIMBERLUX #2, BLOCK H, LOT 10
FRANCIS & JOYCE BEBEY
4825 HILLANDALE AVENUE
ANCHORAGE, AK 99516
7
-� of a�gskll
90
•
Al
'steven R.'Rannone
/Irt� CE 8149 w
r
Date
8/9/2013
Scale
NTS
P.I.D. NO
018-271-45
PERMIT NO.
05P131215
Sheet
2 OF 3
ADVANTEX
4" JIM CAPS x20 POD
ADVANTEX DESIGN
24"
INSULATED
RISER
AUXILIARY
PUMP
BASIN
4" PUMP -OUT/
64"
SLIDE SECTION
OF 6" PIPE
OVER THIS CONNECTION
TO PROVIDE
SHEER PROTECTION -
EXTEND TO
BRIDGE EXCAVATION
x'e�"w"nnawx-m:
12'
PASSIVE
AIR
VENT
INSULATION
INSULATION
%" STAINLESS
STEEL CABLE
6" 0 CHANCE ANCHOR
TYP. OF 4. (GLAV.)
NOTES
FOR CONSTRUCTION
PANNONE ENG SVC, LLC
P.O. BOX 100217 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
SITE SECTION
TIMBERLUX #2, BLOCK H, LOT 10
FRANCIS & JOYCE BEBEY
4825 HILLANDALE AVENUE
ANCHORAGE, AK 99516
--ztThr. titArte• ' �1 2' �y
*: 49 h1 /\
�, '.'k I P.I.D. NO
018-271-45
even R. Pan nsOr; e PERMIT N0.
`� ‘A.
=' ice Sheet 235
Date
8/9/2013
Scale
NTS
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
BETWEEN MUNICIPALITY OF ANCHORAGE
AND RUM x 1 Joyce —:g_v
THIS MAINTENANCE AND REPAIR AGREEMENT made and entered into as of this
Mr Day of SEPI
of 2013 , by and between Thiptuic. 13Fv
herein the "OWNER," and the Municipality of Anchorage, herein the
"MUNICIPALITY." In consideration of the mutual covenants contained herein, the
parties to this Maintenance and Repair Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. Municipality grants permission to
Owner to utilize and operate an Advanced Wastewater Treatment System
(AWWTS), described as
AtwA E$ Sy gal
located at (legal description).
11MBa'zw.uK2 a I-1 Lr IO
2. Definitions.
Alteration. Any change to the design or function of an AWWTS that
includes the installation or removal of any parts, components or pieces not
included in the original construction permit and design.
Certificate of On -Site Systems Approval (COSA). An approval by the
Municipality of existing water and wastewater disposal systems given at
the time of property sale and title transfer in accordance with Anchorage
Municipal Code (hereinafter, "AMC") 15.65. These approvals certify that
the systems are adequate for the homes that they support and meet the
codes that were in place at the time of system construction.
Damage. Any man-made or natural change in a system that would inhibit
the system from performing as designed.
Maintenance and Repair. The scheduled and as needed replacement of
existing parts, components and pieces of an AWWTS that were included
in the original design which would allow the AWWTS to continue to
perform as designed.
Permit. An On -Site Wastewater Disposal Permit as required by AMC
15.65 to construct and operate an AWWTS.
3. Term. The term of this Maintenance and Repair Agreement shall begin on the
date of approval by the Municipality to operate the installed system or issuance of a
COSA, and shall continue while the AWWTS is in use or is operational or until the
property is sold or title is transferred by the owner and a new COSA is issued to the
new owner or transferee of the property.
4. Alterations, Installation and Removal of Additional Equipment. Prior to
performing any alterations to an AWWTS, the owner agrees to obtain an On-site
Wastewater Disposal Permit from the Municipality in accordance with AMC 15.65.
5. Maintenance and Repairs.
A. Throughout the term of this Maintenance and Repair Agreement, the Owner shall
maintain their AWWTS in a satisfactory condition capable of producing treated
septic effluent in accordance with the equipment's approval for operation in the
Municipality. The owner shall enter into a service agreement with an AWWTS
service and maintenance provider approved by the municipality and the
manufacturer of the AWWTS for the entire term of the AWWTS. In addition, it
shall be the responsibility of the Owner during the term of this Maintenance and
Repair Agreement, and any renewals thereof, at the owner's sole expense, to pay
for any and all: (1) repair(s), (2) maintenance, (3) adjustment(s), (4) replacement
costs, and (5) inspection costs.
B. Owner agrees to comply with all applicable ordinance, laws, regulations, rules
and orders for the AWWTS.
C. Upon request by the Municipality, the owner agrees to provide the Municipality a
written schedule of routine maintenance and repairs which have been performed
on the system. When a record of maintenance is documented and maintained by
the system vendor, the owner agrees to allow the Municipality access to this
information.
D. Owner acknowledges that the fine for failing to maintain and repair an AWWTS
may be assessed in accordance with AMC 14.60 for improper discharge.
E. Owner agrees that only maintenance and repair personnel approved by the
Municipality will inspect and make any necessary maintenance, repairs or
permitted alterations to the system.
F. Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS upon 24 hours written notice.
G. Owner agrees that any sale or transfer of title of the property will not occur
without a new Certificate of On -Site Systems Approval.
H. Owner agrees that the AWWTS installation and maintenance requirements as
provided by the AWWTS vendor/installer and approved by the Municipality are
the governing guidelines for the construction, maintenance and repair of the
Owner's AWWTS.
6. Nonwaiver. The failure of either party at any time to enforce a provision of this
Maintenance and Repair Agreement shall in no way constitute a waiver of the
provisions, nor in any way affect the validity of the Maintenance and Repair
Agreement or any part hereof, or the right of such party thereafter to enforce each and
every provision hereof.
7. Amendment.
A. This Maintenance and Repair Agreement shall only be amended, modified or
changed by a writing, executed by authorized representatives of the parties, with
the same formality that this Maintenance and Repair Agreement was executed
with, and such writing shall be attached to this Maintenance and Repair
Agreement as an amendment.
B. For the purposes of any amendment modification or change to the terms and
conditions of this agreement, the only authorized representatives of the parties
are:
a. Owner: T'KR►n . f JDyceasy
b. Municipality: Director, Community Development or designated authority
C. Any attempt to amend, modify, or change this contract by either an unauthorized
representative or unauthorized means shall be void.
8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance
and Repair Agreement shall be brought in the Superior Court for the Third Judicial
District of the State of Alaska at Anchorage. The laws of the State of Alaska shall
govern the rights and obligations of the parties under this Maintenance and Repair
Agreement.
9. Severability. Any provisions of this Maintenance and Repair Agreement decreed
invalid by a court of competent jurisdiction shall not invalidate the remaining
provisions of the Maintenance and Repair Agreement.
OWNER:
By:
12/3/4.3r (5 A "Be L p
STATE OF ALASKA
THIRD JUDICIAL DISTRICT
gnaturup Date: 09. P4, 2 0 1 3
AWN
40:1 fs
�sTATE �F
ticti 14,4:5
'pglll rn#
before me this tl day of (s o
The foregoing instrument was acknowledged
triad/ ANL _
1- Y Pr: LIC FOR ALASKA
y Commission expires: (I' jj
20 1,6, by 4
5
MUNICIPALITY:
Q CNC ,
(signature)
(print name)
Date: g>15-71%.3
Title: CC,7
MUNICIPALITY OF ANCHORAGE
MEMORANDUM
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b12 -7i1 aL
Mark Begich
Mayor
Well Drilling Permit Number: SW
Parcel Identification Number:
Legal Description
ieve.iaprnent Services (:)epartrnent
Building Sc-Fety icn
\ff.Avic.1-ter & Wastevu.c.Teer ProgrcM
4700 9ragaw Street
P.O. gag 19C:Ce350
AricHzracle.„AK 99519-6650
muni.orciirmsire
(9.07)243-7904
Pump installation Log
Date of Issue:
"7 -
Property Owner Name & A.ddress:
rIK- 0-0 lc fX_
4825 A
Pump Installation Date: 7 / 0
Pump Intake Depth Below Top of Well Casing: -•".7Z=. feet
Pump Manufacturer's Name:
Pump Model: C_AS- 5/
Pump Size hp
PitiesAdapter Burial Depth: g- feet
Pitless Adapter Manufacturer's Name: -Ef4--1.<
Ptiess Adapter Installer (4 LAD <?.
-7,/ ell Disinfected TJoa Corniethja?Ys iijNo
i_Yiethod ()CD isinfectio n:
(....ornmentS:
Pump Installer Name:
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation_
AnchoragePage / of 3
Municipality of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 e Telephone: 343-4744
On -Site Wastewater�Disposal System and/or Well Inspection Report
g 0 P--73 PID Number O/3 f7/—
!s ,
Permit Number:
�{{C.t-1/��L �j1i--1--�
Wastewater System: 0 New Upgrade
/f
Address: Lig t4; i
ABSORPTION FIELD
rfL5 1LY:f✓1ln_L,
Phone: No. of De +r oms:
l
D Deep Trench Sheikhs? Trench D Bed D Mound ❑ Other
LEGAL DESCRIPTION
soil Rating:
GPD/Sg Ft.
Total Depth from original grade:
iS
Lot: '^y Block: Subdivision: ,
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
Township:
Range:
Section:
Fill added above original grade:
_'/ FL
Gravel length:
.75 0 Fl.
Gravel width:
Number of lines: 'Distance between lines[
WELL: 0 New 0 Upgrade
Ft_
/ --- Ft.
Classification (Private, A,B,C):
Total Depth:
FI
Cased To:
Ft.
Total absorption area:
/6-0 SG. Ft.
Pipe material:' / t�
CJ/ 7 o r V
Driller:
Dale Drilled:
Static Water Level:
Ft.
Installer: +
TT
Date installed: �j
ei 71
Yield:
Pump Set at:
Casing H ight Above Ground:
TANK iLn [= '� A!,
GPM
Ft
Ft.
SEPAFIATION DISTANCES
D Septic D Holding D S.T.E.P.
To
Septic
Absorption
Field
Lin
Station
Holding
Tank
Public/Private
Sewer Lines
Manufacturer:
Capacity in gallons:
From
Tank
Number of Com ar ments:
Well
/..p -o
11 C
>25
Material: //
/—/h•er 9/w."„'-
Surfacertl0
Water
l Z7
LIFT STATION
Lot//�
Line
19O
: 0"
Size in gallons:
Manufacturer: +�-
/0C� C A G-+
Foundation
i 0
..Pump tove3/y
PumP79vVi-/ (High water al�m�/�
'7t
Curtain
Drain
X10
X10
Pump Make & Model I Flee rical Inspections pertormedb
NEYER- lr%i Vit
r+ 4U SENCH MARK
Remarks:
Location and Description:
Assumed Elevation: (L'Ci
- - i l9 -r%----- FI
: ENGINEER'S SEAL
,-a
)r - Dates 1st 2 1
Inspections performed by:
2nd O'//`14
Department of Flea and F -I an Services approval
�L— Date./044"--
b /
Reviewed and approved .
2-013 (Rev. 9/91) MOA 25
BENCH MARK
\10 FT.
.•��P . . O q<..S •
%\
\
\
\ `
a 49th
... \ \ \
••
TTO: i . SPURKLAN• : Li:
•
•��<j \ No. CE-• 25 ?.'Z♦
•
♦♦•
♦%1P ��PROFESS\CPC' .
.h
Well
1
25
25 50 / 75 100 -125 150
SCA IX: 11" = 50 FT.
TOBBEN SPURKLAND P.E.
203 W 15TH. AVENUE
ANCH. AK. 99501
(907) 279-3916
LOT 10, BLOCK 11, TIMBERLUX S/D
4825 HILLANDALE AVE.
MICHAEL BILLS
SEPTIC SYSTEM AS BUILT
DATE: :SEPT. 26, 1995
SHEET: 2/3 GRID: 3136
1
30
I-1/4' PVC Schedule 50
98±
3/76" Holes ® 18"
5 -WIDE TRENCH
3 Fl. of Cover
4" Topsoil
'
000000oou
0 0 0°0°0°0°
1-1/4" Discharge
9000-�ogogogogogc
D
94./
6" Sewer Rock
1-1/4" Dis/ibulion Pipe
Mirafi 140
94.7
95.2
49th
••
2
r
TUBEN SPURKLAND
•AC:col c No. CE -2225 ��ti"'�
BACKFILL AND LEVEL WITH SAND
97.8
4
BIOCYCLE PLANT
Myers Pump ME40 4/10 HP
BENCH MARKT: BOTTOM SIDING
TOBBEN SPURKLAND P.E.
203 W 15TH. AVENUE
NCH. AK. —391699501
907) 279
BIOCYCLE AERATED TREATMENT PLANT
LOT 10 BLOCK H TIMERLUX 5/0
4825 HILLA/JDALE AVE.
SEPTIC SYSTEM AS BUILT
DATE: SEPT 26, 1995
SHEET: 3/3 GRID: 3136
nOLHFIRE.,GE„ fmLLiiTNIA
1.r.)1),() TUUHH rjUnil
UHOLE:
r.!LOCk7, ',LLY111flirc:,'Cr.LUX -
10;;Yr:LIIHH;
6
:CI
EE.SflNIT.(0, (
• (-1.; ()ft
NY r 10::WITTION r DONT CONCE UNTN,
17, 009 6.
( , 11) r •(.-"(
RECEIVED
SEp 2 8 1995
municipality Qt Anclluta9e
Dept. Health & Human Services
/
,tic LC
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
q -A - a31S
Cic24 1n -\b
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW950273
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:BILLS MICHAEL & DIANE
OWNER ADDRESS:4825 HILLANDALE AVE
ANCHORAGE, AK 99516
PARCEL ID:01827145
LEGAL DESCRIPTION:
TIMBERLUX #2 BLK H LT 10
LOT SIZE: 50470 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
DATE ISSUED: 9/12/95
EXPIRATION DATE: 9/12/96
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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS
SPECIAL PROVISIONS:
THE WASTEWATER DISPOSAL SYSTEM INSTALLED UNDER THIS
PERMIT IS AN ALTERNATIVE SYSTEM UNDERGOING EVALUATION
WITHIN THE MUNICIPALITY OF ANCHOR GR.
C' r. ..
RECEIVED BY:
ISSUED BY:
DATE:f3LC
DATE: //
T.SPURKLAND P.E.
203 WEST 15TH. AVENUE SUITE 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
Jim Cross
Municipality of Anchorage
Department of Health and Human Services
On -Site Service Section
820 L Street
Anchorage, Alaska 99501
Subject:
Dear Mr. Cross;
Lot 10, Block H Timberlux S/D
PID # 018-271-45
Septic System Upgrade.
August 30, 1995
Per our discussion I am submitting an application to install a " BioCycle" innovative system on this lot. The present
ystem is surcharged.and will not
s an
cy test.
les show
w
roundwater
,rg
,e2 Ln and/ or
cl ey `''` v.. sense non percablt iltafeel) The to at on of the well elimits the limits arealableofor a surface mound, the only
conventional system possible on/ this site.
a/sem naeisWe11 intend to excavate an additional testhole in the North-West portion of the lot. If the soil is acceptable there the
drainfield will be relocated to this location, thereby saving substantial disturbance to the property and also eliminating
the long pressureline. This testhole is scheduled for Friday Sept. 1, 1995.
The present testhole has been left open for your inspection.
Yours
Tobben Splrkland P.E.
4 /1
/-.•.,'
i-
1
PROPERTY OWNER AGREEMENT
FOR THE MAINTENANCE OF AN
ON-SITE WASTEWATER DISPOSAL
SYSTEM
This agreement, bated a y,26— 19957 is made between the Municipality of
Anchorage Department of Health and Human Services (DHHS) and the property owner(s)
of: Loi l01 BLOCK 4 Tt►-13e2Lu)C sit)
This agreement is made for the purpose of maintaining an on-site wastewater disposal
system on the subject property.
The property owners agree to the following:
Allow the Municipality of Anchorage the perpetual right of entry to the property during
normal working hours, to allow for effluent sampling or evaluating the general state of
repair or function of the system.
Submit to the Municipality of Anchorage, on an annual besis, an inspection and operation
statement from a registered professional engineer. This irspection and operation
statement shall verify that the engineer has inspected all effluent and air pumps, timers, and
alarms, and that any deficiencies have been repaired and that the system is functioning as
designed.
12_ Q Sl 47,s-
(Signature)
s
(Si nature) (Signature)
Mr e_e 3; ti_s
(Printed Name) (Printed Name)
(Notarize Here)
Rick Mystrom,
Mayor
Municipality of Anchorage Al,
fil
Department of Health and Human Servicesth
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
Dear Homeowner/Prospective Buyer:
The on-site wastewater disposal you are interested in purchasing is an "altemative" wastewater disposal
system. This system, known as a "Biocycle Aerated Wastewater Treatment System", is undergoing testing
within the Municipality of Anchorage under the Alternative System section of the Wastewater Disposal
Regulations (AMC 15.65). There are certain risks involved with the ownership of one of these systems:
1. This system has been shown to be effective in other areas. The system is currently undergoing a
two year testing period in Anchorage under the guidance of the Department of Health and Human
Services (DHHS) and the State of Alaska Department of Environmental Conservation (ADEC) to
determine its effectiveness in a subarctic environment. Testing results on systems installed in 1994
have been very encouraging. Copies of initial test results are available from the DHHS.
2. The Biocycle system has not been tested and approved by the National Sanitation Foundation
(NSF). Currently, Anchorage Municipal Code for Wastewater Disposal Regulations requires
proprietary equipment to have NSF approval. This approval or changes to the Wastewater
Disposal Regulations through Municipal Assembly action will be necessary prior to this system
being approved as a standard system.
3. The "Biocycle" system for this property may have received vertical separation distance waivers
from both State of Alaska and Anchorage Municipal Codes to both ground water and bedrock.
These waivers were granted due to the system's expected performance within the site conditions on
this property. If the test results do not support these waivers, modification or replacement of this
system may be required.
4. If this system fails to meet the requirements set for it to become a standard, code approved
wastewater disposal system, it may have to be removed and replaced by either a holding tank or (if
possible) other wastewater disposal system that meets Municipality of Anchorage requirements.
The cost of any conversions required to meet code requirements will be the responsibility of the
homeowner at the time of conversion.
I (we) certify that I (we) have read the above statements and am (are) aware of the risks outlined. I (we)
also certify that I (we) am (are) in the process of purchasing (property legal description):
it/LC 11cc_ ( N2N B : I t 5
(Purchaser Name) (Purchaser Name)
(Purchaser Signature)
Notarize Here
(Purchaser Signature)
_knit eke''res
T.SPURKLAND P.E.
203 W 15th. Avenue, Suite 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
Groundwater at 7 Ft.
Use BioCycle
Soil Rating.
SEPTIC SYSTEM DESIGN
LOT 10 BLOCK H
TIMBERLUX S/D
MICHAEL BILLS
From test September 1, 1995
20 min/in = 4 gal / sq. ft.
No. of Bedrooms 4
Required Area per Bedroom: 150/. 4 = 37.5 sq.ft..
Total area required: 4 x 37.5 = 150 sq. ft.
Use 5 Wide Trench
SYSTEM CONFIGURATION
BIOCYCLE AEROBIC PACKAGE PLANT
5 -WIDE TRENCH
TOTAL LENGTH 30 FT.
TOTAL DEPTH 3 FT.
ROCK DEPTH .5 FT.
COVER 3 FT.
ABANDON EXISTING SYSTEM
The installation of this septic system will not prevent wells from be installed on the adjacent lots.
There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots.
The proposed septic system will not change the general slope of the area. Ponding and/or
concentration of surface runoff will not result from this installation.
pg.1
T.SPURKLAND P.E.
203 W 15th. Avenue, Suite 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
SEPTIC SYSTEM DESIGN
LOT 10 BLOCK H
TIMBERLUX S/D
MICHAEL BILLS
Groundwater at 4 Ft.
Hardpan at 8 Ft.
Use BioCycle
Soil Rating. From test August 29/1995
23 min/in = 4 gal / sq. ft.
No. of Bedrooms 4
Required Area per Bedroom: 150/. 4 = 37.5 sq.ft..
Total area required: 4 x 37.5 = 150 sq. ft.
Use 5 Wide Trench
SYSTEM CONFIGURATION
BIOCYCLE AEROBIC PACKAGE PLANT
5 -WIDE TRENCH
TOTAL LENGTH 30 FT.
TOTAL DEATH 3 FT.
LAKE OTIS GRAVEL 3 FT
ROCK DEPTH .5 FT.
COVER 3 FT.
ABANDON EXISTING SYSTEM
The installation of this septic system will not prevent wells from be installed on the adjacent Lots.
There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots.
The proposed septic system will not change the general slope of the area. Ponding and/or
concentration of surface runoff will not result from this installation.
pg.1
3
5C
0 50 100 150 200 250 300
SCALE: 1' = 100 FT.
10
Ayr
•
TOBBEN SPURKLAND P.E.
203 W 15TH. AVENUE
ANCH. AK. 99501
(9071 279-3916
aid
TDBE91 SPURKLAND / 4j
No, CE -2225 ,.afr'
Ct 47
♦e��.p. LJJI �l�
LOT 'h ,,"PZOCK H, TIMBERLUX S/D
4825 HILLANDAL£ AVE
MICHAEL BILLS
2
12
2
SEPTIC SYSTEM DESIGN
DATE: AUGUST 28, 1995
SHEET: 1/3 GRID: 3/36
Install BloCyde
Abandon
Exist, Septic To
1
il 49th
•
•� TO: . SPURKLAND Li•
0. ,CI) ••• No. CE-• 25 •° _• fir
i
•1111****So***
Well
e_vlsef q/lij'9f
TOBBEN SPURKLAND P.E.
203 W 15TH, AVENUE
ANCH. AK. 99501
(9071 279-3916
LOT 10, BLOCK 11, TIMBERLUX S/D
4825 HILLANDALE AVE.
MICHAEL BILLS
SEPTIC SYSTEM DESIGN
DATE: AUGUST 28, 1995
SHEET: 2/3 GRID: 3136
1
30
1-1/4" PVC Schedule 50
7
J/l6" Holes 11 18"
5 -WIDE TRENCH
SECTION A -A
4" Hollpipe 6" LONG
1-1/4 PVC Holes Pointing Up
3 Ft. of Cover
/ 4" Topsoil
1-1/4" Discharge
•••�E oF. ,q..0
�GJ ��s
•
i {a
49th 0
% /
070 ti
0 vn 70B EN SPURKLAND 4 (oa:
•ICf• No. CE -2225 . =,i
T.
•+',017tESstIsKte
Ves.,;sa lots
BACKFILL AND LEVEL WITH SAND
On On
o o oc0
on n n0ogon
6" Sewer Rock
1-1/4" Dis/ibulion Pipe
Mirafi 140
ism
BIOCYCLE PLANT
Myers Pump M£40 4/10 HP
BENCH IAARKL:
4
TOBBEN SPURKLAND P. E.
203 W 15TH, AVENUE
NCH. AK. 99501
907) 279-3916
BIOCYCLE AERATED TREATMENT PLANT
LOT 11 BLOCK 5 SOUTH HILLS
7501 EAST 140771. AVE
SEPTIC SYSTEM DESIGN
DATE: AUGUST 30, 1005
SHEET: 3/3 GRID: 3136
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
f r' I Ii 14c •ei I IIS
LEGAL DESCRIPTION: L01— Io BK 1+
45 /101 3
4
• 1 i W-i?9a i2 L u x
,26A-1,-11 Ls
s
10
11
12
13
14
15
16
17
18
19
20
LL, roc Li
CiCt:14t7
.ris, .....,c 4 ,�
11
B'e. . '°a,E'.
10 '9
Oe .0.•.. ..c -.u..,,,
o el
® 0. T
t ol• en Sporldnnd • 4
44,
'Q Th so
',1•. CE -7225 e •'
4 '2 ei .••...e..e•.��.'aisle /. /
DATE PERFORMED®®�RQpre ® 'Z %,
Township, Range, Section:
eo4erv.ti of Rat -e
Heti-a at
SLOPE
4)
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth to Water Atter Li
Monitoring? 7 • Date.
,/
S
L
0
• p
E
SITE PLAN
1
N
L
`Z ti
Reading
Date
Gross
Time
Ne
Time
Depth to
Water
Net
Drop
FILL
s/4IVO a'
I4 -e s
4, 4.- 6t-
F/Zrlgf
?Az 5;',-l7
7'e,
I; v 5
.ria
/0 1-117.4
/o •34
/fl
c2:0 s-
/ D
A "
s/g
7
/n'
/ice
544.
166
a- 5'
/0
6 /`i
ti //4,
3
1U
6 3/{k,
r1bb
t/L
46'
ry
3 VS/
//j6,
5.:;
0
6/ 'Gg
/k
P.3 3:u e; /V y �/�
P
PERCOLATION RATE .3 (m'nutes?inch) PERC HOLE DIAMETER
q /
TEST RUN BETWEEN 7 FT AND �3 Z FT
6 t7//L
COMMENTS
PERFORMED BY:
CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
�1�)1 /9%
PERFORMED FOR:
i �z
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
LEGAL DESCRIPTION Lp•- to
I - 1144,10-er
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
SITE PLAN
N
S
L
IF YES, AT WHAT
5 o
DEPTH?0
L
-e L
P
E
Depth to Water Al c�///�
er /
Monitoring? ( Date
Reading
Date
Gross
Time
Ne
Time
Depth o
Water
Net
Drop
r—;//
4V,/
9:30
taVy
p:zs-
sprig-
:38
:3E,
/0 mi h
't 1 3/6
-"T/g
'I LS
10
l/°
34
// 37A
3 0
3: 00
/ 0
I I°
5/4
h
o3
rr 3i„
/0
/
fi3/�i
r/Z
PERCOLATION RATE 020
1((2� Id -'/v
(a-Is/inch) u3tes/inch) PEHtO HOLE DIAIJE&P€R
TEST RUN BETWEEN 624, FT AND 3 FT
COMMENTS
I/L
PERFORMED BY'
/e ?
CERTIFY THAT HIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
Kd>.71�
72-013 (Rev. 3/78)
cjJ MUNICIPALITY OF ANCHORAGE 1 J
NAME
(I
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
a ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE
T fl`1 ` �}} 11EW
V, !VE!��.F-. IS'/J'/R?C`
I mi UPGRADE
MAILING ADDRESS j
P D. 8d$ /O- 7-77 Ari - ei96 o/
LEGAL DESCRIPTION
140 2 H •/7s'y1,Liek u 9.2_
LOCATION
NO. OF BEDROOMS
U
DISTANCE TO:
Well
)
/G1 ,
Absorption area
Dwellin 9
.-10
PERMIT N0--'—
' "Steil
F Z
m Q
NH
Manufacturer
_ ttiw.$`G-:1�
Liq. in
jj
Materi 5
Ie%7k.c
No. of compartments
c pacify nylons
�/JUrJ
IF HOMEMADE:
Inside length
g
Width
-2
Liquid depth
X
DISTANCE TO:
Manufacturer
Well
Dwelling
PERMIT NO.
_ F
0
Material
Liquid capacity in gallons
DISTANCE TO:
Well ,,.Foundation
/
Nearest lot line
PERMIT NO.
LI W
l—
~ Q F
No. of lines
Top finish
Length of each line /
/
Total length of lines
1f ` r
Trench width
- 3�' inches
Distance between lines
.___—
of rile to
grade/
, J�7' /
Material beneath tile
i
inches
Total effective absorption area
VV dt
w
Length
Width
Depth
ff55
PERMIT NO.
Q F-
w a Crib
w
Type of crib
Crib diameter
depth
Total effective absorption area
w
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Clasa�/�£
/
Depth _
Driller `_ _
Distance to lot line
PERMIT NO.
V
DISTANCE TO:
Building foundation
Sewer line
Septic tank
_
Absorption area(s)
OTHER
PIPE MATERIALS
01--
(/
1) ,?0C3` -
P
Lf�
SOIL TEST RATING
,ll
9"-C
N
)
- yctzf
INSTALLER -
201/P- LIKE
f�'��
REMARKSl.
Cc;
/
act
/eS.nL;:L'.. '7/ES /44- Sit.) cc -.-K S zzvV_
.
144j
-t tt,
71
,_ry
t'r; Jc'
SEllG.
644 It ih] it1 ttra,0-#-isn^— `4tdn&
9
109 0 toke..s is b. -ski 4, A use M.ACL f si:
W0 --
APPROVED nn-rr '',.,,,
Kd>.71�
72-013 (Rev. 3/78)
r4 r ir (-.) Fr EN-P0 ;���
PEPARTMENT /` HEALTH ANENYIRONMENTRL ` E
. YOTECTION
B25 /\ /ST�FET HNCHORH�E F� ���� �
^/ / ' '�� 9+".�4
264-4720
PERMIT /~�m�»�����C I��� ��EE��fl ����M I r
- ��~. ` `^-`^�' /
L. 0 y)p/ ^^,'
APPLICANT J. ucu."
��^~`�. .�cncn FO BOX 1@`77� ANCHORAGE 99511
ATInN
LEGAL 110 BLOCK H TIMBERLUX #2
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
LOT SIZE 999999
// LI`t
• (ll_gc,wa9-°' u"mnXrunu NUMBER OF .-DRUOMS
= ~3T SOIL RATING (S4 FT/BR)- /195
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
PDEIF,MH= LAENT3C-FS= ��4-r.,2PEEd...
THE LENGTHDIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH DR DRHINFIFLD
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
uxxUMP nND THE BOTTOM OF THE EXCAVATION (IN FEET)
THERE Is NO SET WIDTH FOR TRENCHES �
THE nRHVELDEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFHLL PIPE
AND THF BOTTOM OF THE EXCAVATION IN FEET).
]45-1229
��P.-.:4:1! Li "r��
17S rA "St: ET_ = fiL CD CE-11L.A. Cs INS
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
TmsTALLA|1UN INSPECTIONS OF ANY WED ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE
��� ��������� ��� ����
---�� ���������FR' �
��>
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS ^--^--
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN WELL AND ANY DN`SITE SEWAGE DISPOSAL SYSTEM IS
: 100 FEEFOR HPRIVATE WELL OR 150.TO 200 FEET FROM H PUBLIC NEL. DEPENDING
UPON THE TTYPE ':fl> PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO 9 PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY !SEWER LINE IS 75 FEET.
AND CONSTRUCTION DIAGRAMS ARE
AVAILBLE O INSURE PROPER Ir�ALIA.Ium.
0;7'.' I U "7'4:: F." 11.4:" �Cr.= M Lr;';'��11D:CE7
I CERTIFY THAT
I HM FHMI| IHR WITH THE REQUIREMENTS FOR ON-SITE SEW£RS AND WELLS AS
FORTH EY !HE MUNICIPALITY OF RNCHDRRGE
2: I NIL) L INSTRLL THE SYSTEM IN HCCORD�NCE WITH THE CODES
• EN_ -- REMODELED
TO HDP ,/ORE THAN 3 BEDROOMS.
SIGNED.
ISsUED
HPPLICHNTJNEHER
u � -/ .
, _ ,��� ��j ���� 6-77���)F� ��'�' ][�� ���!) /^ Lc 82
-7 1 /
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THE
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SO II
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}`_•`-i:-(0.?t iz k?FlT 14n .. r. OR 1'6+3 TO 2C9 Fr r i=R'llt H rl.Ya_I #43
$ 1 ✓13jd iia S t`P;i" it' 7%h?3_ Es: Lk --1
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Ii4:'al r;r ua 72.v.E.2 ! F;7'i Cr'H.t_..0 EOM
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of?L?tF Pr
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GRE�4.riev
21t ANCHORAGE AREA BOR\ GH �/ 76,
Department of Environmental Quality
)J'13 7�
3330 C Street '/
Anchorage, Alaska 99503 :K vt!�C:
✓-
INSPECTION REPORT ON-SITE SEWAGE DISPOS�AlL�SYS EM
'4 /Grp .et MAILING ADDRESS r4/4
Ptt ;: PHONEc24/.--
LOCATION/? aagi iltI LEGAL DESCRIPTION I /Q te4V'. //)7� �C/2)
SEPTIC TANK:
DISTANCE 'I �/ pp
FROM WELI UA/ „2-425/MANUFACTURER Y/,vser MATERIAL
INSIDE LENGTH INSIDE WIDTH
TQC' GG,
D:
DISTANCE FROM WELL FOUNDATION /©
/0/;96//C—
NUMBER OF
COMPARTMENTS
LIQUID DEPTH LIQUID CAPACITY/QC) GALLONS.
�.- TOTAL LENGT
NEAREST LOT LINE -e� OF LINES
NUMBER OF LINES / DISTANCE BETWEEN LINES
TRENCH WIDTH IN. TOTAL EFFECTIVE
ABSORPTION AREA SQ FT LENGTH OF EACH LINE
�}
DEPTH OF FILTER
DEPTH: TOP OF TILE TO FINISH GRADE 7/4%MATERIAL BENEATH TILE �+
IN ABOVE TILE IN.
WELL:
'y�;J'/
TYPE a01�` .f/�dONSTRUCTION
DEPTH
BUILDING NEAREST NEAREST
FOUNDATION LOT LINE SEWER LINE TANK SEPTIC f/ SEEPAGE
SYSTEM
CESSPOOL
APPROVED
OTHER SOURCES
DISAPPROVED
DISTANCES•
A C -
AZ.1/6
INSTALLED BY. coez,s e -r>
•
SEWER LINE DEPTH -
PIPE MATERIAL
LOT SLOPE: 2&6/C /
DISTANCE FROM:
REMARKS
DIAGRAM OF SYSTEM
REMARKS•
Form E4-032
DATVt 24 7CAPPROVED
G.A.A.B.
WATER WELL LOG
FOSS DRILLING
1336 Ingra Street
Anchorage, Alaska 99501
MUNICIPALITY OF ANCHORAGE
HEALTHDEPT. OF
ENVIRONMENTAL PROTECTION
DEC 91976
WELL OWNER t Chin N��-J�}n / rrUSE OFHomo
omo
LOCATION iQt JD R)06.4Ii 1in,bt/t.✓y 5j1) -c1 GIw sL:4Dn //.;
RECEIVED
SIZE OF CASING I "DEPTH OF HOLE/QbFT. CASED TO / 0
STATIC WATER LEVEL 98 FT. YIELD GAL.PER.MIN. WITH ci-it
FEET OF DRAWDOWN.
REMARKS
FT.
DATE COMPLETED II/0/7 /n
fit
£toD
(2t oa
'5 r� t oSe
/itoLD4
1.Qto22,6
to
to
to
to
to
to
to
to
to,
to.
t 0,
to
t0_
PUMP TO BE SET AT
nes Ftejt
(►Try, San d Gra.✓, I
('Vey, 5a»d Gra3/4
(1la, y Siad Ji Gntiv✓/
(IA% Sar d a) Growei
6/cvyl, 5wn 6ru.✓4./
Sam I� (ravt/
J3rn
Gre )/
6 rt y
A1tAie t
Gr.� y
641
fhurd
Ji to/
14 .
1'Itd
(A)Ait t>✓r
i4;ZJg Cluj
El P-4 ®_ I1�, RL I re e`®F eRt-•de_ F 1 ^o- eate;E f/
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION -
2516 E. TUDOR RD.. ANCHORAGE: AK 9951:17
6-2221
bJ L L a= -e PA C.--• 01%4 -- s; 1L `E F E_ R2 r i
PERMIT NC'. ( 76766 4: a '-
APPLICANT .JIM NEHR 801. AIRPORT HTS
LOCATION HILI_HP�dCHLE AVELEGAL L± -i. 0 E TIME:ERLU(:;
_,L
27
SUE: LOT SIZE 54455 SQUARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ
THE SOIL.ABS0RPTION SYSTEM IS:
LENC31Y' F -R = 4 C3F°E °"e°F- L
1
274-9452
THE REQUIRED
SIZE OF
1'95
L>EEF" T R -R _= ' ^
THE LENGTH DIMENSION 1S THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
F.:E-® eLe I Rte'E'c-. SEF•1F I ®_. "Te---et--0C -E_ -u eO
"TWO •_:.` :s I t-J_"F"Ec:—r I u3tJ
E,ACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN FI'WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
1400 FEET FOR A PRIVFITE WELL. OR 200 FEET FOR A PUE:LIC WELL.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
INSTALLATION. •
FOR: met --0E °-e-°Eh=eRu_ FR _c®R^R ISSUE".
I CERTIFY THAT
1: I FIM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELL=, AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
=: I UNDERSTAND THAT THE ON-SITE ::EWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE:
RESIDENCE IS REte DELED TO INCLUD'E9 MORE THAN 3 BEDROOM=.
SIGNED:
r-�3
APPLLCANT JIt9 NEHR
ISSUED BY._
C
_DATE _/ Y /7- ?
, 047
•31VDS
aihnssv wnlva
SNO11VA313 ON115113 PO
135 NJVI 0 any .21..i 0
A3G1:1n5 51141 135 UV1/3H 0/5 0
0383A0338 8V0311 0/5 •
ON3`J31
1-1 - of tl 01 j.v -I
:NO11d183530 1V931
Nis
NOSN30 0 NVO 'B
aOA3AHn5 ONV1 038 '81" 11VONVel 01V2139 IAB 03avdJtM
'30V2:10 HSINU 01 NOI1V138
NI NOIIVONl1O3 AO dOl NO3H0 01
A1f11011SNOdS3N SHOIOVNINOO 31-11 SI 11 ^
— �t
Oc\
• *.:'L
\\ego
'1SIX3 S1N3WHOVOLIHON3
ON ONV S3NI1 AL83d08d 3H1 NIHIIM 38V
NO383H1 031Vl11S S1N3113A08dWI 3H1 1VH1
ONV No3213H 030ILJOS30 CNV NMOHS A1U3dOi1d
l 3H1 03A3AL111S 3AVH 11VH1 A111833 A0383H 1
: NOIIVOLi11213Q A3ANf1S 101
d I Itt 714M1
,v�
\
29 \
270.1)(11 \,'1>r, 5.10,409 hi
C Jorzsetu tton EJ .t .1 1,)
"Ona testis worth a thousand opinions"
2204 Cleveland Anchorage, Alaska 99503
Performed For Jim Nehr
8/3/76
Leval Descrintion: Lot 10 Block H Subdivisionte TimberluxPerfoed Subdivision
This Form Renorts Soils LOO yes
Percolation Test yes
Depth
Feet Soil Characteristics
fop`sozl
?ere 4 — Brown Gravelly Silt (ML)
:est Gravelly Sandy Silt
8--:..e.—� -Y,
:one
10--
12- –
0
12- Silty Sandy Gravel
14__
16 --
20_
Bottom of Test Hole
Was Ground Water Encountered?
If ves, At what Depth?
No bedrock encountered.
Reading Date
I —
No'
Gross Time Net Time
8/27/76 saturate •eriod
8L30/76
L 8/30/76
8/30/76
8 30 76
8 30 76
Percolation Rate 1"/15 Minute
Proposed Installation: Seeoaae Pit Drain Field
Depth of Inlet Den—ft—To Bottom Of Pit Or Trench
CnmMENTS: 195 square feet drainage area required_p_er bedroom.
72 hrs
Depth to H2O
inches
20.00
Net Dron
inches
Test Hole Empty
0 � 19.75 0
3.0 hrs I37.75j 18
3.5 hrs
4.0 hrs
40:25 1 2.5
42.25 1 2.0
Test Performed By j 4,2!x , /, 144, g/ T Data Certified By: CONSTRUCTION:TEST
aures D Mack Date: 8/376 LAB
ALASKA CflUIROflrpcflTAL COIITROL SSRUICCS, Inc.
engineering & €nuironmental Studies
6/17/82
SUSAN NEHER
P.O. BOX 10-771
ANCHORAGE AK 99511
MUNICIPALITY OF ANCHORAGE
Cyr., T.7.1
^.
18 1952
RECEIVED
SELLER - SUSAN NEHER BUYER-
SUBDIVISION-TIMBERLUX #2 BLOCK -H LOT -10
ADEQUACY TEST FOR SEWER SYSTEM
THE TYPE OF ABSORPTION SYSTEM IS A TRECH WITH AN UNKNOWN AREA.
THE SYSTEM IS CAPABLE OF ACCEPTING 150 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 6 GALLONS.
THE SYSTEM IS UNACCEPTABLE BECAUSE THE SURGE CAPACITY IS LESS THAN
75 GALLONS.
THE SYSTEM IS NOT CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY.
THE SEPTIC TANK WAS PUMPED ON 4/16/81 .
SEPTIC TANK ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF 1000 IS ADEQUATE FOR
THIS 3 BEDROOM HOUSE.
n"t'e OF 44 Mil
,,........a
.,c^. •• osa_ of
e 60,11
goi, re
to sone •J? In e
1„
for y C. Reid, Jr. • 4
/00
:0 % No. 2251•E* Vg's+
@4%®9OFESS P49.
1220 West 25th Avenue • Anchorage, Alaska 99503 • (907) 276-1361
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES (t,e
`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
l-7,5 HAA# W CC .®4-iAtik
omplete legal description
ocation.
fess otherwvisejr guested HA;
MBEROFBEDROOM
'S
,r::� ✓ « '3 t req
TYPE OF WATEF;i'.SUPPLY�xy��
4bindividual well
.u�nCa'+Sq s'-bra--:•.by,.�sr�-ia'2s�3.�ks�a-r,='
y & n SCom_mumtywel
'
h?'s�z Sa 2 �'j
ublic water
-jtii c4.a t•d'y a._t,� t i"'S�^� s4�.i,-o-`S�j
DOTE If community weltsystem,' provide written confirmation from St41YADEC attetstl
ung to the legality and status otsystein * $ %C SVC! i.
YPE OF WASTEWATER DISPOSAL _ ; 1Ci
fiy`aJi��'�avatirrgs.-.
oldlng`tank
j' ' ` , c Communityon.site i a �Fe ' i t
t S 3"l' L riF✓«i i 3:c�,"is
rx> 3Publtc`sewer
lfcommunitywastewatersystem, provide written confirmation from StateADEC-$
attesting to the legality and statues ofsystem
7-025 (Rev: int} ;Front ;MOA 221
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 sate, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm (0hLr pu'rLCLek k / 1 E. Phone
Address -90LliO '
Engineer's signature
„Lt<�2'LG
Date 1/9‘/% 3
6. DHHS SIC . TURE
Approved for 4_ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the :wing stipulations:
By
Additional Comments
CAUTION
jai
The Municipality of Anchorage Department of Health and Human Services (DHHS) is.:ues Health
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 (aev. 1/91) Back MOA 421
D. LIFT STATION B l 0 C'-/ C L IE
Date installed 14-3/93' Size in gallons
Manhole/Access (Y/N) "Pump on" level at* ie // "Pump off' level at*
(
High water alarm level at* 2 7 i! . *Datum I 0 I cs-c- 1 a..ii. Ire
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
I
Septic/holding tank on lot //2.0
: On adjacent lots
Absorption field on lot 1 15 ; On adjacent lots i /0-0
Public sewer main 1 z/,4, -
Sewer /septic service line
90'
Public sewer manhole/cleanout
NSA
Lift station 1 Z 0
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
i I
Building foundation cat, Property line is0 Absorption field 69- `a
Water main/service line >oab Surface water/drainage 1\1 0 Wells on adjacent lots > / 0-0
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
Surface water
yo
N10
Curtain drain HID
F. ENGINEER'S CERTIFICATION
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots > 70'0
1 certify that 1 have determined thru field inspections and review of Municipal
in conformance with MOA /IAA guidelines in effect on this date.
Signature /%
Engineer's Name { p .e. ✓i Cr U '� %rte lat t2 -PX I
Date 240. Alp Lei 95-
HAA Fee $
Date of Payment
9-2
Receipt Number /331J 3 a p
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Property line
/2-0i
recordsahatthe above systems are,
o
g Seat•Fiaee
CF: 2225
9
Date of Payment
Receipt Number
Legal Description
A. WELL DATA
Well type
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
10f/010kI •77144hert ,e
Log present (YM) N1
Total depth
lift
Parcel I.D.: 018 -
If A, B, or C, attach ADEC letter. ADEC water system number NIA
Sanitary seal (YIN)
Date completed 1 � 7 2-
Cased to > y (% Casing height (above ground)
FROM WELL LOG
Date or lest
Static water level
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK/DATA
Date installed c/3(y Tank size
Nitrate
Wires properly protected (Y/N)
AT INSPECTION
9/L Z/e/
rn
rn
1 -n
0
W.?
I SYri N/, I CW -11'141 414A -e -a l
CW -11141
Collected by:
Other bacteria
0
Cr)
CO
CD
01
1' x
t'? Z
<n o0
•c:
T
r;1 G
v, G`
fl rt,
7:
g.p.m.
10 50OW. /07.-W
0
13LDcYct_t
Number of Compartments / Clcanouls (Y/N)
Foundation cleanout (Y/N) Depression (YIN) /2%-1
Date of Pumping
N/A
C. ABSORPTION FIELD DATA
Date installed e1/43A
Pumper
High water alarm (Y/N)
Soil rating (g.p.d./ft` or ft'Ybdrm) 4"
Length , 0 Width Gravel thickness below pipe
Effective absorption area / J 0 Monitoring Tube present(Y/N) \l Depression over field (Y/N) rI
System type 6-- tie, c -A
// /
ry Total depth
Date of adequacy test
N/A
1 fJ
Results(Pass/Faiq � For -/
W Immediately after gal. water added
Fluid depth in absorption field before test (in.);
Fluid depth ✓ (ins.) Minutes later:
Peroxide treatment (past 12 months) (YIN)
(in.):
Absorption rate r/ g.p.d.
bedrooms
v
If yes, give date
CT&E Ref.#
Matrix
Client Sample
Client Name
Ordered By
Project Name
Projectq
PWSID
CT&E Environmental Services Inc.
La boratory DivisionEx®®®®Basssrsriasszrmdr®a®®®,�®s®®sms�®®®®®®®gym
95.3983-1 Laboratory Analysis Report
WATER
ID LOT 10 BK H TIMBERLUX
TOBBEN SPURKLAND, P.E.
TOBBEN SPURKLAND
UA
WORK Order
Printed Date
Collected Date
Received Date
17997
09/18/95
09/13/95
09/13/95
Q
14:58
15:30
17:05
Technical Director STEPHEN C. EDE
Released Bys—`
Sample Remarks: SAMPLE COLLECTED BY: T.S.
Parameter
QC
Results Qual Units Method
Allowable
Limits
Ext.
Date
hrs.
hrs.
hrs.
Anal
Date Init
Nitrate -N
* See Special Instructions Above
0.10 U mg/L EPA 353.2 10. 09/15/95 CMR
** See Sample Remarks Above
U:= Undetected, Reported value is the practical quantification limit.
IY = Secondary dilution.
UA = Unavailable
NA = Not Analyzed
LT = Less Than
GT = Greater Than
200 W. Potter Drive, Anchorage, AK 99518-1605 — Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
47s/97
-c 11
Application Date /f<G al/94-7
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lar/0 114.4-1
Location (address or directions)
t/gst�-�&
#a cep._ 3 VTh!N,&'3ifi/
(b) Property Owner patNn*-+S Ple1.4 `J Telephone:7�Home .1"/S-- /4/Business 7s-6- 3`y 3/
Mailing Address «Rif l/%t/ o( fl- 99 yL
(c) Lending Institution 6,W4C Telephone
Mailing Address/1 L
(d) Real Estate Company and Agent {- �i 109 t '^ps% A
�` "" SiPruD_
Address .3a�A 1 C
Telephone 6(v 3 -55 0-0
(e) Mail the HAA to the following address: or: Check here
List contact person and day phone number below.
7—
if hold for pick up.
,22q- s 9f'b
2. TYPE OF RESIDENCE
Single -Family O.
Number of Bedrooms
9
3. WATER SUPPLY
Individual Well Community 0 Public 0
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 0 Community 0 Holding Tank 0
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
72-025 (Rev 8/861 Front
Nue (99/9 AO ) GM -LC
Z 10 Z abed
')IJOM %Jaaw6ue
leuo!sseJoad agl u! suolss!wo JO S/0119 ,10; alq!suodsaJ lou s! a6eJogouy;o Auledlo!unIN ag1 'penss! s! aleo!ppao a eJo;aq
elep ez<,leue Jo suolloadsu! lonpuoo lou op SHHO to saeAoldw3 'sluaweJ!nbaJ aims pue impel u!e4Jao Als!les 01 Japao
ul suopnlpsul 6u!puel maw pue sawoq to saasegoand of /sa1JnoO e se slgl scop SHHO ag1'9)!sely;o ale1S aql u! paJels!6aJ
Jaaul6ua leuo!ssa;oad luapuadapu! ue Aq anoge g gdeabeaed u! uan!6 suo!leluesaadei eql uodn Apo paseq saleo!;!1Jao
IenoJddy Aluoglny UlleaH sanss! (SHHO) saolnJas uewnH pue g11eeH to luaw29da0 obeaogouy;o Rl!led!oium aql
NOI1nVO
CIOVor
19uolllpuo0
,L 8— arZ�.S' ale0 'r nispht . �.
leas s,ieeu!6u3
•
lenoaddy leuo!1!Pu0O to SWJa1
panoJddes!0 panoaddy
Aq swoapeq 7`p2 ✓+.1L Jo; panoaddy
IV✓AOHddV SHHO '9
Tt6T 'St 3Nnr
�'.' 3-9ZZZ
..it
P,.644p
G�i2V
(7/6C/b1-75 auogdalal / O V
Sea
'uopoadsu! s!ql 10 a19p aUl
u0 10311a u! suopeln6aJ pue'seoueulpJo'sawn owls pue led!o!un4 119111!M eoue!ldwoo u! s! wals%s lesodslp Ja19Ma3seM
Jo/pue llddns JOIBM ops-uo eql 'uo!loadsu! pug uo!196!lsanu! Aw woi; pue sell; e6wogouy to A1!led!a!unW aql wag
paulelgo uonewao;u! aql uo paseq lwUl Awed\ Jagpn; ! 'want' paleo!pu! aanlonais 10 edAi pue swooapaq 10 Jegwnu aql Jo;
ewnbape pue leuo!lOun;'a;es s1 wals/s lesods!p Ja39MalseM Jo/pue Alddns Jawm e11s-uo ag11eg1 smogs lenoaddy Aluoglny
Ul19aH s!Ul10 uope6psanu! Aw 1947 Anion 1'Malaq uMogs alep uo!lepllen 014110 se pue oTeJeq pax!;;e leas, w Aq pa!;!1JOO sy
NOIIVW!IOJNI ONV VIV0'HO8V3S 3111 131931'SNOISO3dSNI DNIOIAOHd INHId ONItl33N10N3 '9
0190
ssaappy
WJld 10 aw9N
U
MUNICIPALITY OF ANCHI IANECIPALITY OF ANCHORAGE (MOA)
ENVIRONMENTAL SERVICES/REALMAUTHORAUTHORITY
APPRO L (HAA)
CHECKLIST
4
MAY 2 71987 264-4720
Legal Description Lor 1 f, l a V_ f4 I I 1--1BEILLI7x
SLC- sti i/2N,
RECEIVED
A. WELL DATA
Well Classification 12 e -s. If A, B, C, D.E.C. Approved (Y/N) ryr
Well Log Present (Y/N) Date Completed W/7%=4'/ Yieldr4„2#
Total Depth 10P, Cased to (0 & Depth of Grouting I'4 O HJ
Static Water Level Pump Set At //o
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) 1 Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot (Let ; On Adjoining Lots >I UU
To Nearest Edge of Absorption Field on Lot 1 .6 0 a-
" ' On Adjoining Lots J r U n
To Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot
Water Sample Collected by ; Date
Water Sample Test Results
/ % /1
Comments JXi
Y �ayq Te/f [sii tF
.� . u`t` Lr a,"1.4�.d
< lcal Ela C4-JaLL.�
B. SEPTIC/HOLDING TANK DATA
Date Installed
i / Size /P-sv No of Compartments "7"1✓io
Standpipes (Y/N) / &it-)
Depression over Tank (Y/N)
Air -tight Caps (Y/N)
y
Foundation Cleanout (Y/N)
Date Last Pumped 3/4c-../8,
7
Pumping/Maintenance Contract on File (Y/N) N/�1 ; for WA
r
Holding Tank High -Water Alarm (Y/N) W/A Temporary Holding Tank Permit (Y/N) TVA-
Separation
VA
Separation Distances from Septic/Holding Tank:
ILC
To Water -Supply Well
To Property Line
To Water Main/Service Line
To Building Foundation
To Disposal Field
elelo>
5
/ To Stream, Pond, Lake, or Major Drainage
Course "? r {�>
'7 % +0 tutu
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
;2,2:5`
Type of System Design
Date Installed 10 ('1 E 1 2181 Length of Field 9 *S
Width of Field Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
1 ty2
(1
1./
Standpipes Present (Y/N)
Date of Last Adequacy Test
frv' 2itlecielrmejvt:r�>
0 n!/L�
Separation Distance from Absorption Field:
/'5c.t.
To Water -Supply Well
To Building Foundation
Lot
NI o v1
To Property Line
To Existing or Abandoned System on
• On Adjoining Lots > °-C>
To Water Main/Service Line ) /01 To Cutbank (if present) /VU/1/i
To Stream/Pond/Lake/or Major Drainage Course //0 i p. nor volt- /n 0/ra ' a_.ay clic-4
To Driveway, Parking Area, or Vehicle Storage Area //.7
Comments 4 (Jen1//n i{+ h&vv./ w-aZA.�y..-... eJ1
/
1.446 4qs/....„ tit "44 .!, & y
D. LIFT STATION W /
EFT
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
"" Check Permitted Bedroom Rating Against HAA Request ""
I certify that I have checked, verified,rconformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed % " �'/�t L`L`au Date /A /12d /
Company
MOA No
Receipt No ca - 0007
Date of Payment S- a 2- C-1
Amount: $ /0 0
AL V--00/-007
Page 2 of 2
72-026 (11,84)
, 9111 t .a
0 2225-E
I1' JUNE 25, 19 1
Engineer's Seal
Municipblity
of
Anchorage
May 26, 1987
P.O. P 7 196650
ANC RAGE, ALASKA 99519-6650
(907) 343-4200
TONY KNOWLES,
MAYOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
Dennis Money
4835 Hillandale Avenue
Anchorage, Alaska 99516
Subject: Waiver for Lot 11 Block H Timberlux Subdivision
Waiver Number WR87-031
Dear Mr. Money:
After visiting the above mentioned lot to verify land contours
between your drainfield and surface water, your waiver request
has been approved. The required 100 foot separation from
surface water to drainfield has been waived to 42 feet. This
approval was granted because your drainfield is on the opposite
side of a knoll from the subject surface water. In the event
your drainfield were to fail and begin to overflow, effluent
would be directed away from the surface water in question.
This waiver applies to this existing drainfield only and any
future upgrade may require another waiver request from D.H.H.S.
ncerely,
Daniel J. Roth
Civil Engineer
On -Site Services
cc: Gus Andress, P.E.
Water Quality/On-Site Services Project Manager
TOTING ENCONSULUUL
tNLWJV D)203 W. 15th AVE "C" SUITE 203
9 o�o MOND;ntaY ANCHORAGE, ALASKA 907)2799501
RONENr.HEACTHE
t oorEcION
MAY 2
7987
RECEI QED
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 6-6650
ANCHORAGE, ALASKA 99501
MAY 26, 1987
SUBJECT: REQUEST FOR WAIVER OF SEPARATION DISTANCES FOR
PRIVATE WELL, AND SURFACE WATERS.
LOT 11, BLOCK H, TIMBERLUX SUBDIVISION
DENNIS MONEY.
Gentlemen;
We are submitting a request for waivers from the separation
distances stated in Title 18, Alaska Administrative Code Chapter
80.020
The closest standpipe on the septic tank on Lot 11 is 97 feet
distance from the well on lot 12, which was installed at a later
date than the septic system on lot 11. Also, the developer of
lot 12 improved the surface drainage of that lot by ditching and
thereby created or changed the drainage pattern of that lot,
which resulted in a small pond 40 feet distant from the end of
the drainfield on 11. Representatives from your department
inspected this drainage situation to -day and indicated to Mr.
Money that a waiver would be granted.
Yours
Tobb-n Spurklan. P.E.
cc. tennis Money
• U O o V1 GFJP1a7AADD9 Pulta
CONSULTING ENGINEER
1203 W. 15th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE (907) 279-3916
RESIDENTIAL WELL INSPECTION
LEGAL: LOT 11, BLOCK H. TIMBERLUX SUBDIVISION
LOCATION: 4835 HILLANDALE
OWNER: DENNIS MONEY
TYPE OF WELL: SINGLE FAMILY
WELL LOG AVAILABLE: YES
INSTALLATION REQUIREMENTS MET: YES
WELL YIELD FROM WELL LOG:
PUMP YIELD:
DATE OF INSPECTION:
4 GALLONS PER MINUTE
4.5 GALLONS PER MINUTE
MAY 14, 1987
TEST PROCEDURE: WELL WAS PUMPED AT A CONSTANT RATE OF 4.5
GALLONS PER MINUTE WHILE THE DRAWDOWN WAS
MONITORED WITH AN ACOUSTIC PROBE. AT THE BEGINNING OF THE TEST
WATER LEVEL WAS FOUND AT 72 FEET BELOW TOP OF CASING. AFTER 38
MINUTES OF PUMPING AND DELIVERY OF A TOTAL OF 215 GALLONS THE
WELL WAS AT 100% DRAWDOWN AND THE PUMP SHUT OFF. RECOVERY WAS
MONITORED FOR 70 MINUTES. 50% RECOVERY WAS OBTAINED IN 13
MINUTES, 75% IN 25 MINUTES AND 97% IN 70 MINUTES. BASED ON
RECOVERY RATE WELL YIELD IS 3 GALLONS PER MINUTE.
TEST FOR COLIFORMS: WATER WAS TESTED FOR COLIFORM BACTERIA AND
NITRATES ON MAY 18, 1987. BOTH TEST WERE
NEGATIVE.
TEST RESULT: THIS WELL MEETS THE REQUIREMENTS OF THE
MUNICIPALITY OF ANCHORAGE.
The Municipal requirement for well flow is 150 gallons of water
per bedroom per 24 hours.This well surpasses this requirement.
The assessment of the condition of this well applies only to the
conditions as of this date. The flow rate of the well may change
due to subsurface conditions that may not be observed from the
surface, and changes in land use and other factors that may
impact the conditions of the aquifer feeding the well.
rJ
CONSULTING ENGINEER
. ada�a9 P L
203 W. 15th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE: 19071 279-3916
SEPTIC SYSTEM ADEQUACY TEST
LEGAL: LOT 11, BLOCK H, TIMBERLUX SUBDIVISION
LOCATION: 4835 HILLANDALE
OWNER: DENNIS MONEY
RESIDENCE: SINGLE FAMILY, FOUR BEDROOMS
WELL: PRIVATE, ON SITE
SEPTIC SYSTEM: FROM MUNICIPAL RECORDS:
TANK: GREER STEEL, TWO COMP. 1250 GAL.
ABSORPTION SYSTEM: TRENCH
ABSORPTION AREA: 900 SQ. FT. FROM MUNICIPAL
INSPECTION FORM. 744 SQ.FT.
FROM FIELD MEASUREMENTS.
SOIL RATING: 225
INSTALLATION DATE: JUNE 1981.
DATE OF PUMPING: MAY 18, 1987. ISAACS PUMPING SERVICE.
DATE OF TEST: MAY 22, 1987.
TEST PROCEDURE: SYSTEM WAS INSPECTED AND MEASURED TANK WAS FOUND
WITH 3.5 FEET OF COVER. TRENCH SUMP WAS 7 FEET
DEEP AND THREE FEET TO TEE. TRENCH WAS FILLED WITH WATER TILL
WATER ENTERED THE TANK. A TOTAL OF 2200 GALLONS WERE USED, WHICH
CAUSED A 38 INCH RISE IN WATER LEVEL.
INFILTRATION RATE WAS MONITORED FOR 18 HOURS. DURING THAT PERIOD
WATER LEVEL IN TRENCH DROPPED 10 INCHES INDICATING AN
INFILTRATION RATE OF 580 GALLONS PER 18 HOURS.
TEST RESULT: THIS SYSTEM MEETS THE CODE REQUIREMENTS OF
THE MUNICIPALITY OF ANCHORAGE.
The operational life of all septic systems depends on the local
soil conditions, groundwater levels that may fluctuate during the
year, and the water usage of the family being served by the
system. These conditions are outside the control of the evaluator
of this septic system. We can therefore not give any estimate of
how long the system will continue to meet the operational requi-
rements of the Municipality and State.
,_1
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
FEDERAL TAX ID #92-0040440..
Client P0# : VERBAL Req #:
Client Smpl ID: LII, B4 TJMBERLLV
Sample Recd : MAY 14 87
Ordered By
REPORTS ADDRESS #1
TOBBEN SPURKLANUPE
203 IW 15TH AVE, #C-203
ANCHORAGE, AK. 99501
ANALYSIS REPORT BY SrwIPLE
Spec ia.i COPIES HELD FOR. PI OK UP.
Instruc t: ROUTINE SAMPLE TAKEN BY TOBBEN SPURKLAND, 5-14-87, 1200 HRS
Chemiab Ref #: 6258 Lab Smpl ID: 1 Matrix: Nater
Parameter Tested ts
N 1 T RA T E -N
Sample
Remarks:
1 Tests Performed
ND= None Detected
NA= Not Analyzed
ND (0.100 mo/1
Mork Order No. . 574
Client Account : TOBBENP
Date Report Pr inted: MAY i8 8? ? 18.3-
Rel eased BY
REPORTS ADDRESS 142
ADEC
Al towable
Method Limits
* See Special InstructlonsAbo've
** See Sample Remarks Above
LT=Less Than, GT=Greater Than
CHEMICAL; & tEOLOGICAL LABORATORIES OF ALASKA, INC.
LABORATORIES
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
FEDERAL TAX ID # 92-0040440
,
f1t4-1TYSIS REPORT BY SAKIP1 E
01 it PO4 : ARPFIL Reg #1
CI int STrip ICI: LI I , P4 TIPIBERTUX
Samp 1 e Ref:" d MAT 14 87
Ordered BY !
REPORTS ADDRESS #1
T088E41 SPURKTAND
203 IT I 5TH 0416, 14C-103
PITCHOKAGE, AK. 99501
ci al COPIES HELD FOR PICK OF .
ins ta t KOUTINC SAMPLE TAKEN aT TOLIBEN SPURKLAND, 5-14-37., 1200 HRS
Ch Ref 14: 8,258 Tale 84'01 10: 2 Nab' i (4ater
Par erria ter. Tas t ed Re P.1 I Ugh i tS
TOTAL COL I FORPI 0 roi/100m1
Work Order. NO. ; 524
CI enthccount ; 1:000209
Date Repor t Pr! ted 37
Released 44y
REPORTS ADDREaS 142
:4E0
1 eEtE ESHOPITI9d See 9eca} inatructcirbov!?
None Lscts :nrr,!, !.57.5ii!!! Ken:ark KKdeDeddd . .
•
Le,dd Hat fTh !C. St! !_i=!.!!SS tRif 4T1-rter
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
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range) ',, /
A 69 tea
Location (address or directions)
4:gge /////, wp, e Ave %/Uc/J cia ', 4e 99S/G
(b) Applicant Name L 13/1--e-6 Telephone: Home
� � J� .94226-g627, Business ��, �/9,�
Applicant Address 4676 /�// tiM/PP( T/V2 /4jj�al® Wee 4c 9937
(c) Applicant is (check one): Lending Institution 0 ; Owner/builder Buyer 0 ; Other 0 (explain)•
(d) Lending Institution_f7Gf/
Address
(e) Real Estate Company and Agent A/o/y._
Address
Telephone
Mail the HAA to the following address:
17- /hay/ ,ci✓a//(6-2/1 7 % /th6,0
?�D.S Aec77e 8oilz, s//7.- 99'
A/a/D at, %;C 996.0
aro/52-
Telephone lib ` 769°
_1_�� /il/i✓�os� �G//� A�/o���-9903
(f)
1/P
2.
2. TYPE OF RESIDENCE
Single -Family Multi -Family 0 Other
Number of Bedr��`ooms
3. WATER SUPPLY
Individual Well
Community 0 Public 0
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 0 Community 0 Holding Tank 0
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
72-025 (11/84)
``
5.' ENGINEERING FIRM PROVIDII (INSPECTIONS, TESTS, FILE SEARCH, DLA 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.ns�// //r
Name of Firm !% /k C/✓ai/V�irie'/V Telephone 7b
Address
Date JAI 8•C'
6. DHEP APPROVA
Approved for bedrooms by
Approved
41%6000p 0
ao.
ra%P°49111
o'*I
° j�Qinaert;®& el!Oa
1�0000eoe
ro 00 00000aoou0000��CyyOE90�foo Li
pannla efl8 ^VF e
CE 5909 °e
X0000000
°Ind
ppA �p
wag elle
Disapproved
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
/25 OM/1°
DFr
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design %.�iGgeh
//3Frl)
g, 5 r &
o<r
Length of Field
Depth of Field
Gravel Bed Thickness
No
SAVA PAcra X.i
Separation Distance from Absorption Field:
To Water -Supply Well /24r7-
29Fr()
To Building Foundation
Lot
To Water Main/Service Line
Standpipes Present (Y/N)
Date of Last Adequacy Test
}lc
7/8//86C)
To Property Line /2Fr'C2
To Existing or Abandoned System on
/oofrr
• On Adjoining Lots
/y'lA0 To Cutbank (if present)
A✓/,4
To Stream/Pond/Lake/or Major Drainage Course
Z
To Driveway, Parking Area, or Vehicle Storage Area /0 / rT
Comments a) /&2// Doer ,9ECO.epS
(V crew c d --&r6 ,wEA retem W,,r 7/sY/O6
D. LIFT STATION (A//4)
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at \\
Tested for
Electrical Codes (Y/N)
Comments
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
1 certify that I have check dtv ified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Ma— �� Date ff,it no
Company -1 .f11644 CfJCP6OCEl'{�ll MOA No
Receipt No \ O \ ®`o a- 3
Date of Payment
Amount. $ \O S .b
Page 2 of 2
72-026 (11/84)
•
141/47
74-1
• Dennis .
D
CE - 5
P'1iii.lZt'
f
e
A. WELL DATA
MUNICIPALITY OF ANCF Y CIPALITY OF ANCHORAGE (MOA)
DEPT. OF HEALTH HEALTH AUTHORITY APPROVAL (HAA)
ENVIRONMENTALP----IO,tHECKLIST - FEBRUARY 1984
1986 264-4720
RECEIVED
/-/ij /52
Legal Description: (97-4 C /�
T/ev cs-032 A/9-
4825 ///G P14t6 1o'e
Well Classification �2/U4re If A, B, C, D.E.C. Approved (Y/N) u/A
Well Log Present (Y/N) Date Completed ////�/7l% Yield 4 7�7PA'
Total Depth /06FT O Cased t /06fr 1 Depth of Grouting /VO/Vo
Static Water Level 11- arr. 0 Pump Set At /(9,gfT
Casing Height Above Ground , �U e) Sanitary Seal on Casing (Y/N) ' / ��/�
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) /Y
Separation Distances from Well: �
T 6� FT
To Septic/Holding Tank on Lot /ASF" ; On Adjoining Lots /
z,cr.
To Nearest Edge of Absorption Field/ on Lot ./2 t7 • On Adjoining Lots ____//0/>71-
To Nearest Public Sewer Line N/A
To Nearest Public Sewer / /
Cleanout/Manhole N/A �/� //Too Nearest/stSewer Service LineonLot .—_/ //4
Water Sample Collected by s er !iV/ 1 7 % Date // Vg
Water Sample Test Results SAY1S toil timi
Comments e -O$ 17//6P ,2ECoePS ,
0 A&OA1 4A.,-S/r€ M,,ASU.lMENrS 7/6//86
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
62
Depression over Tank (Y/N)
Size /�001/A/ No oLCompartments
Air-tigtbt,Caps (Y/N)
,, /CCyJJ
/Y Date Last Pumped
2 -
Foundation Cleanout (Y/N)
Pumping/Maintenance Contract on File (Y/N)
• for
Holding Tank High -Water Alarm (Y/N) /' Y' Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well /5/7-6)
To Building Foundation
To Property Line / 7.tFT r0 /V >t To Disposal Field // rCT v
To Water Main/Service Line t/A•• To Stream, Pond, Lake, or Major Drainage
Course
Comments Flo/ ae/ep ,eeco,eos
® F,eo,w av-wre Aleds,ee,ce/Ts
Page 1 of 2
72-026(11/84)
A+Home Services
15900 Francesca Drive
Anchorage, Alaska 99516
345-1890 • 345-2444
DATE 8'-i -0 6
fif
/l iAsq,�7/s/
diga.� J // k n1 -Da /e-
cla-_31,7 -
/96/S2
DATE
DESCRIPTION
CHARGES
CREDITS
BALANCE
PREVIOU CE
62 44 4, I , . / 4 0 - - i
40
_
4 O szetze;tt
l %0
�0
G B /"
7mi/ �t,oc. )25-0_2700
Cq(
y s"Se ye_ 6e/Qo/ .;-/wK
BALANCE DUE I>
0
If this statement does not agree with your records please notify us at once.
STATEMENT
PI PFMm' 111
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE ) �
1. General Information Application Date c_ii `. ) HO
(a) Legal Description (include lot, block, subdivision, Section, township, range)
Ttrrnb6K�Ltx * a Lot I t i31 oc. A fy
Location (address or directions)
(b) Applicants Name U%i`%.f"�rC,y3 0n001)E- C,DO.�>4_� Thlephore:5q -31"7'J
"n
Applicants Address l(] `1 I r I D\ d 5E L1)a a
(c) Applicant is (checkore) Lending Institution n ;[Owrrer�/builder ;
Buyer r ; Other Ii k(explain);
(d) Lending Institution Telephone
Address
I C
(e) Deal Estate Co. & Agent (( AnnLe 60.1-1-s4 -�.I R; p 1�.', nn
�.Lt n
Address ' -�I l P i 0 t d SEC- UDC (ZC^
Telephone 131-119- u? (`l I
2. Type of Residence
Single -Family
Number of Bedrooms
3. Water Supply
Individual 4 11
Multi -Family
1
Other (describe)
Communityi Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting<to the legality and status.
Is the well adequate for the number of bedrooms specified in this'HAA ] I)
4. Sewage Disposal
Onsite Paq Public $j Community $1 Holding Tank
Is the wastewater disposal system adequate for the nunier of tedrocros ON)
(Page 1 of 21
2-15-84
5.. Engineering Firm Providing Inspections, Tests, Data and Information
I certify that I have checked, verified, or conformed to all MDA HAA Guidelines in
effect on the date of this inspection.
Signed C. /°� / /ui 24Le747 Date n' /f i R1aal
Name of Firm '1E C;.S ,
Address X20,0 4).. 33 :16: 6
Signed by
Date 3/1/ ti
(ENGINEER SEAL)
6.DHEP Approval
Approved for / bedrooms
Approved rsaDisapproved
Terms of Conditional Approval
Telephone .5-6 SZ1 7O
ti
.c- S- • •.�.1S ®0
4' •°°4.9 9D
•
figict
6 o•c acc.V
'• Lero 0C2251�E ,r?4� ®
•
BY% VcZ-- Date:41.±._;1_::
Conditional L. 1
The Municipality of Anchorage Department of Health and Environmental Protection does
not guarantee the continued satisfactory performance of the water supply and/or the
wastewater' disposal system. This approval indicates that, as of the validation date
shown above, based on the data and information furnished by an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and func-
tional for the number of bedrooms and type of structure indicated.
(DHEP SEAL)
7. Mail the HAA to the following address:
KB2/d5/s
[Page 2 of 2]
2-15-84
A. WELL DATA
Well Classification Zialwaduki If A, B, or C, D.E.C. Approved(Y/N)
Well Log Present (Y/N) YE -5 Date Completed y//7/gy Yield y 9 po
Total Depth /013" Cased to dth.4N00 a Depth of Grouting 1"'14,16tet,u
Static Water Level Iv1/44 V o'h. Pump Set At itiw►tttoWh�
Casing Height Above Ground /.i/' Sanitary Seal on Casing (Y/N) Ves
Electrical Wiring in Conduit (Y/N) Yes Depression Around Wellhead (Y/N)/04
Separation Distances from Well:
To Septic/Holding Tank on Lot /IV' ; On Adjoining Lots /00 '4-
To
tTo Nearest Edge of Absorption Field on Lot /3O' ; On Adjoining Lots /400.04_
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Lot 11 Block AlTimberlux Subdivision #2'
To Nearest Public Sewer Line
Cleanout/Manhole N/4
Water Sample Collected By
Water Sample Test Results
Convents
N/A-
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
�. %urn er' ; Date 2/204
N/A -
B. SEPTIC/HOLDING TANK DATA
Date Installed /,l$/ Size /2-5RD No. of Compartments
Standpipes (Y/N) CIES Air -tight Caps (Y/N) yts
Depression over Tank (Y/N) ftJp Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) /4,4 ; for Ain
Holding Tank High -Water Alarm (Y/N) N14 Temporary Holding Tank Permit (Y/N) A!/,*
2-
Foundation Cleanout (Y/N) Yes
Separation Distances frcm Septic/Holding Tank:
To Water -Supply Dell IAD/ To Building Foundation 20
To Property Line s_ yD' To Disposal Field 5�
To Water Main/Service Line tsjfr To Stream, Pond, Lake, or Major Drainage
Course N I /}
Col nts
[Page 1 of 2]
2-15-84
48 -ST -Z
goa33a
uT 9euTTepTnJ ywH
(� LS •oN 1/09411,4d (Opv'AV0441/1i11143
VON Tie
ege0
[Z Jo Z 05ed)
9/SP/TEM
•uoTgoadsuT si.g 3o egep egg uo
og pemaojuoo ao 'pe gTaw 'pepa4o ene4 i Begg A3Tgaeo I
* gsenbeg yfH gsuTeby 6uigflp
ee wooapeg patuued eu3
VON sgaaw
•gsay Aoenbepy 6uTanp SeToAO 6uTdwnd
(N/A) gueA
sgua uop
(N/X)90po0 TeoTagoaTO
42 TeAe7 030 dwna„
(N/A) ssaooy/eToquew
suoTsueaTO
ao3 pegsey
ge Tanal waeTV aageM 46TH
ge :canal ,,u0 dmndu
suoITeo uT ezTs
PeTTegsul 0420
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sgua:wroO
eeay e5eaogg eToTq0A ao 'eeay 6uTjaed 'icemen -a0 oy
it Is
esanoO OSeuTea0 aocew ao/axevpuod/weeaas oy
-41iy (guesead 3T)NueggnO oy //N
i+IN s4o7 buTuToCpy uo
uo wagsAg peuopuegy'ao buTgsTxg oy
,6
sun e Tnaes/uTew aegeM oy
aura Zgaadoad oy - ,orf
:pTeTa uoTgdaosgy
prl6 0(2°) SQT,
3o egeO ()iv (N/A) pTeTa aano uoTsseadec
eaay uoTgdaosgy 3o geeg eaenbs
/,Role 49q, I,aenbapy gse'I
5?,6 (N/A) guesead sedTdpuegg
a ry o tv goy
uoTgepuno3 6uTpTTng'oy
TTeM ATddns-zeieh oy
woa3 aDuegs10 uoTgeaedeg
ioenbepy gsel 3o sgTnseu
sseupoTgy pee Teneao
PTaT4 3o 4gdec
uroo1l wV1
PTeTA Jo 41PTM
i 06 PT°Ta 30 41bue71 W9 peTTegsul 9420
#fl'19ar/ u5TseO megsAg 3o edAy
Sz?'
egeagg uoTidaosgy uT buTgeg STTOS
VIVG O'IOIa NOISdaOSSV • 0
ALASKA dIT If10I1f11Cf1TRL COf1TROL SCI CIiCCs, inc.
engineering & environmental Studies
FEB 29 1984
WAYNE AND ANNE COOPER
6917 OLD SEWARD HIGHWAY
ANCHORAGE AK 99511
SELLER — WAYNE AND ANNE COOPER BUYER —
SUBDIVISION — TIMBERLUX #2 BLOCK — H LOT — 11
ADEQUACY TEST FOR SEWER SYSTEM
THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 900 SOFT.
THE SYSTEM IS CAPABLE OF ACCEPTING 600 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 600 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A
4 BEDROOM HOME.
THE SEPTIC TANK WAS PUMPED ON 2/29/84 .
FLOW TEST ON WELL
THE WELL FLOW RATE WAS 1.9 GPM FOR 4.25 HOURS.
SEPTIC TANK ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR
THIS 4 BEDROOM HOUSE.
'41 .d
P e
F✓u es 2o
e -'
d®� L- a C. Reid, J . <• %o -J
4 u o. 2251-E a
fcSo/ .4tY
AAWtHe
1200 West 33rd Auenue. Suite B • Anchorage, Alaska 99503 • (907) 561-5040
ALASKA dTOIROf11116f1TAL COf1TROL sSU(CeS, inc.
Engineering & enuironmental Studies
March 1, 1984
Mr. Keith Bandt
MUNICIPALITY OF ANCHORAGE
Department of Health and
Environmental Protection
825 L Street
Anchorage, Alaska 99501
Ref: Timberlux #2 Lot 11 Block,2' y
Dear Keith,
This letter addresses the discrepancies in the septic system on this lot as
per our phone conversation of February 29, 1984. As I pointed out, the
total effective absorption area recorded on the inspection form of June 10,
1981, does not match the other recorded data. With a trench length of 93'
and a gravel depth of 4', the absorption area should be 744 square feet, not
900 square feet as recorded on the inspection form. I can confirm a trench
length of 93 feet, the gravel depth cannot be confirmed without excavation
or drilling.
The problem arises in that this is a 4 bedroom house and 744 square feet is
not adequate. The original design was for a 3 bedroom house, as was the
approval. The design called for an 85' trench with 4' of gravel.
Apparently this was adjusted in the field to a 93' long trench. The
inspection form does comment to "Hold for 2nd soil", so it could be that an
additional percolation test was performed and the design adjusted. But only
the original 225 soils test rating is listed. In Mr. Spurkland's report,
the soils are rated as having a highly variable percolation rate and 225 was
recommended as a safe rating. It might have been adjusted if they
discovered better soils while excavating.
I performed an adequacy test on this system on February 28, 1984. The
system tested out as adequate for a 4 bedroom home. We cannot tell whether
or not the error on the inspection form is due to an error in calculation or
a change in soils rating, but the variable percolation rates reported by Mr.
Spurkland tend to indicate that the soils could be better than the 225
rating. The fact that the system tested out as adequate for a 4 bedroom
house tends to support this.
I recommend that this system be termed adequate for a 4 bedroom house.
Sincerely,
SAwAr
'wen Turner
nvironmental Scientist
1200 West 33rd Auenue, Suite B • Anchorage. Alaska 99503 • (907) 561-5040
Time
APPLII ,,NT FILLS OUT UPPER HAS ONLY
Property Owner o.-rn-c s
Mailing Address » n R (4
'P- S (AAS A Yl) K Altive 1
to • 2--/) I r C.„n. Pk Zip Code �'99S) -
V- (11Ctc-I\\in1'h t-. CUO.ber
p t ? --.
G t 1 Ar 4,Ai -Code cO
J.Z� + F rklc�,��l � , 9
Phone
j(15i aa.9
.
Buyer Qo,1C.1cl /\. WL.he..r
Address7✓
SSU C � iJ.�
Lending Institution
Address
-
I- l p-A,t_0 J1q6Af•,rc 6nr
Phoneele-,LL,
P7Ki-& U°
11i{
[!l 41. SA-Trq-"le-.-P,h--(ik-,;—. t-- Zip Code 99570
Realty Co. & Agent. p )
I A O L -7
Address - w MI �—
✓ (e`f\-\-- - Lac{ \ E-6-1-0 Y\ t
o-ra. Pr -'27.155-2-
rZip Code
Phone
en,- 7 66
S
LegalDescriptionL
Street Location
c _J
l
/4 1 11(.x!
D e, �it`.-} t, 1�,\;N- &
c R- Q (i1
Type of. Residence
gSingle Family
Multiple Family
❑ Other
No.
p
of Bedrooms 'S
_
Water Supply
. Individual
Community
❑ Public Utility
(j ) APPROVED BEDROOMS
( 3) DISAPPROVED
( ) CONDITIONAL APPROVAL ..y
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).
Sewer Disposal
gIndividual
Public Utility
❑ Holding Tank
G //
Year Individual Installed: / / 7 W _
When Connected to Public Utility:
..-�
1 `t' � J�-`'V Ml91
{ 6,-,6)
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time -4 UJ V
Time
Cc. 7•
„'h
"%
atet,nun
Date
Date -
Date
1(l-'�1-1-qa 1 kmLA
Date
to - VA
.a
.a&), --
Inspector
Inspector
Inspector
Parr{ O.
Inspector
P, &
Field Notes: �� — InAl'po4
t+N- I -
Li. Aip or (--,-
� v-
oo
Pi of
�
0e-
11s IE:!"
(j ) APPROVED BEDROOMS
( 3) DISAPPROVED
( ) CONDITIONAL APPROVAL ..y
'B6 " OF APP OVAL
�/"l/0 �, ''" _� /
^-y 'C't j �- ..W -t t (/W '--2Lw-1
WCl
BY. C7 -(-,GYM. /
..-�
1 `t' � J�-`'V Ml91
{ 6,-,6)
Soils Rating
461
Date Sewer Installed
tb -At
Well To Absorption Area
Well to Tank
Well Log Received \I
Septic Tank Size /.0ave)
7242313/82)
/
INSPECTION APPOINTMENTS
DATE RECEIVED
.erruSi;
TIME
TIME
,_ KA A$, AcP
TIME
PL , 0 hOJAufd h!i
DATE
DATE
1- 11)-q\ (kJ_I_f5.
DATE
-2-- E1Qobbb
INSPECTOR
• COMMUNITY since June 1975. For wells drilled prior to that date, give well
c_)-)INSPECTO
, �
14
MINSPECTO Qj)
UNICIPALITY OF A/4 LP
DEPARTMENT
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION
OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
Jul 2 9 1981
SANITATION DIVISION
Telephone 264-4720 RECEIVED
OF INDIVIDUAL WATER AND SEWER FACILITIES
•.
-J.( 4 i _ ENVIRONMENTAL
REQUEST FOR APPROVAL
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days fo processing.
1. PROPERTYOWNER
.774A-SC4- 6e -w p
PHONE
37, 37/'7
MAILING ADDRESS
',CA ' &)( 9/� - J. A iC
PROPERTY RESIDENT (If different from above)
1-/`( A-426,3,-4 (('/C
PHONE
2. BUYER �7
COil'ely�e/ 4 Cha 7 e--1--"-
f�MAILING
PHONE
MAI LING ADDF(ESS
3. LENDING INSTITUTION
ae.m •
PHONE
0276 //3z
�
%74I
MAI LING ADDRESS
V /V i�-z-cL
1.e
4. REALT R/AGENT LZ
PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION /—
/a 7L 7/ 8/e (4 ( 6w /0 y s�-,6/.
STREET LOCATION %/
7/! GYL.-t f(In--, 1 cl—' '
6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS
0 One • Four 111 Other
fel SINGLE FAMILY
0 Two • Five
■ MULTIPLE FAMILY - en Three ■ Six
7. WATER SUPPLY
lT INDIVIDUAL* *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
EN INDIVIDUAL/ON-SITE** (/1%pc YEAR ON-SITE SYSTEM WAS INSTALLED.
0 PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
f2t
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
• SINGLE FAMILY
IN MULTIPLE FAMILY
NUMBER OF BEDROOMS
O ONE O THREE D FIVE O OTHER
O TWO ■ FOUR O SIX
2. WATER SUPPLY
O INDIVIDUAL
■ COMMUNITY
O PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
EINDIVIDUAL/ON -SITE
•PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
OSeptic Tank or IN Holding Tank
Size: If Tank is homemade
SOILS RATING
give dimensions:
TYPE OF TANKMANUFACTURER
) 2- S(m Cy4-9.j.` s-m5
TOTAL ABSORPTION AREA
MATERIAL -
� € \ OCYh M \ L s,
Li{-C9.1. c� o k civ g ( \)
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption ea
A
Sewer Line
Nearest C5)Line
Absorption Area to nearest Lot Line
5. COMMENTS
Ile. APPROVED FOR - BEDROOMS
• CONDITIONAL APPROVAL (letter must accompany certificate)
O DISAPPROVED
DATE
1 — 25 \ --' 8 \
BY
\c„....5.----
mbe
72-010 (Rev. 6/79)