HomeMy WebLinkAboutTANAINA VALLEY LT 15
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND I'IUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl. INSPECTION REPORT
TANKS
SEPTIC [~ HOLDING
TYPE OF SYSTEM
TRENCH [~ BED ~//W. DRAIN ~] OTHER
on§inal grade J/ FT_
,5' F'r
.J,.~q~ 8QFI
WF-LLS
PRIVATE
~' OTHER (Identify)
Depth ET Cased to
FT
REIVIARKS:
DISTANCES
~ TO
FRO~
WELL
LOT LINE
FOUNDA'[ION
SEPTIC
TANK
ABSOItPTION
FIELD
/&pl
WELL
Municipal and Slate guidelines in ellecI Oll Illis dale: .
Health Deparlment Approval: '~ ~" /-
72 013 (3/85)
~l,~7,~cediJ, y Ihal lhis inspeclion was periorlned according Io all
M IJ N I C I I:::' A I- ]: T Y (] F:' A I'1 C I'1 0 R A i3 E
Dl~l:)ar, tl¥~-HYL o{' Health
835 L. St, r'eet~, Anchor'agE:,, Alaska 99501 343-.4720
0 Ixl .... S ]1] IE !3 E: W E R F) E R M
Per, mit Number'~ 8EKX)7
Oate Issued: 06/02.
Eng z r'leeP DesignE~d
I}E~31131q,S Iisi
70~:?.1 DRIF:-I'W[IOD L. ANE
ANCHORAGE:, Al<
Day Phone:
349-80 14
I:::'aP c:e i I d: 0 :L :L-'05 :i,-.90
I....o'L I...egal.". E~ubdivi~ion." TANAINA V~L..L;E¥ ~UBD,,
E~ect ion~: 4 'Townsl"~ip, 1~%t Range, 4w
Lot, ~3:i. z e
Max Bedrooms: This I::'er'mi'L~ 4 Total Capac:ity~ 4
SIEPTIC, 'TANK:~ Mir~:l. mum total septic 'Lard.:: capacity,". J.~,:?,50 gallons. [ii'.ac:h septic
'Lank must. h~w.~ at Ie~s'L 2 compal, tmerrLs. DE, p'l:.h 'Lo t. op o{: s~eptic 'Lank (s) < 4.0
INl:::[)Rlvi :O.. H, H, E)., Pl:tI[ll:~ TO :I. ST & ~)NI:> INSPEC'FIOixhS BY
AI:;']'I:ZR [)F:'I:::'I[:',E IIOUREi []ALL, 343-4681 AND LEAVE A
i]ONEFH:;~LICT I:::'1}!]1::~ I:i]xl(i]IlxlEE:.'R~ ATTACHIED AI:::'PROVED DESIE)Ixl
IHIS I:::'EI:~MIT I:~:XPIRES
T'i.I I ,{'3 I:::'E,I:;~M I 'F I:.'OF~ A ,S I NEiI...,IE: F;'AM 11_Y R F-:,~3 Z DIE,:NCE ONI.,Y
Cli~i]:~"l' I F:'Y FHAI'~
I alii }'alll:i ] :LaP ~i'Lh t, hE:~ I"~qL~il'~!l~le?~)'~.~ f'£]P ~FI"-'!~i~'~.E~ ~e~ti:q'Ei aFid W~;I ].~!~ ~'~ ~;i~.~'~'..
fortl'l by the Mur~icipaJ, it, y of Anchor, age~ (MI]A) and 'Lhe , LaLe o~' Alaska.
~l'll:J J. rl c:omplJ, arll:::e wi'Lb 1:.h¢~ (:l(a~L~Jf] cpiter, ia of this permi'L,.
I ~:i,],l adher'e to ali. M[]A and S'La'Le of hlasl-::a f~.~qLlil"lallleITl:.~i rOI" the ~l.::~t. bacl::
d i~)'l:.a~l"ic;E~s f I"(;:)rll ~;~l"ly ~x i~'lL :[rig we]. ]., wastewat, er' d ~.~posa]. .sy.stem or pub 1 ic
s(.:;~wePa~ge s'ystem on 'Lhis oP E'd'ly adjac;ent oP near'by lcd:,.
I t,.U'lElE:)r'E~ta':ugd 't,l'h'~'l:. t, his per'mit :i.s va].id fop a
also undep~d',.ancl 'that t.l'~:~ c::ap~'Ly of the t.o'Lal ~y~te,I is 4 bedl'ooms ar'id
a~llS' (~)Fllal"ql(.~fll(~arYL u$il], pl~cll.iiP~ju'l additiona:L I::)er'mi'l',
ssued By: . DATE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 %." Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:__
DATE PERFORMED:
LEGAL DEECRIPTION: /-.-O-/- / ~-
1
2
3-
4 -
5 - p~/E£ L
7
8
9
10
11
12
13 -
15-
!//~.~££~./Township, Range, Section: ~;¢7C7- ,'C-
ELOPE SITE PLAN
17 -
18
19
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH? pO
E
Dep~ t~ Watu ~er
MoniLoring? ~_ Dale:
Reading Date Time Time Water Drop
/ " .¢ .~ ?,2'~ i,o
~ " d ~ ~ o d~-1 ,3, ~o
20
PERCOLATION RATE =?...&., ~'~' {m~nutes/mcb) PERC HOLE DIAMETER ----
TI-'ST RUN BETWEEN ~'~ FT AND ~ FT
COMMENTS ._~-b mO~l,
AOOORBANCE WITH ALL STATE AND .UNIOIPAL GUIDELINES IN
72-008 (Rev. 4/~) ~ /
,',, I
'1
5
Michael E, Andorso~]
438~ E
RASPOERRY
T
6
16
$1:040 t&
I
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I,D. ~
CERTIFICATE OF HEALTH AU'rHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
- c~ O '~ NAA# _
1. GENFRAI. INFORI~IATION
Complete legal description
Location (site address or directions) ~_ocuCL, L_ ~P.~U~ OFF:
Property owner
Mailing address
Day phone .5'¢.¢- ,5 /l..~ __
Lending agency
Mailing address
Day phone
Agent
Address
Day phone
Unless olherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. 'rYPF OF WATER SUPPLY:
NOTE:
5/ \f
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADE. C
attesting to the legality and status of system,
;'2-025 (Rev 1/91) Fronl MOA ~21
STATEMENT OF INSPECTION BY ENGINEER ..,
As certified by my seal affiX~J~"h'~'~:et'0 and as of the validation date shown below, Ii~erify that 'my
investigation of this Health Authority'Approve app cat on shows that theon-sit~ ~yater supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herei'n. I ffirther 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 wastew~ter 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
Address
EngineeOs signature
DHHS SIGNATURE
' X App;o~ed fo; ~--C'¢~''- (z/,)
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
/~.~..._~ · ~,¢,~-x% Date
By:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority'
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued, The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: _ & [5 TAklA/klA \/A I leu
A, WELL DATA
Well type CO ~nl fJ/J I~¥_ If A, B, or C, attach ADEC letter.
Log present (Y/N) [:)ate completed
Total depth Cased to
Sanitary seal (Y/N)
FROM WELl. LOG
Parcel I.D. _O II- 0,~'/ ~ cio
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Pubtlc sewer main
Public sewer service line
ADEC water system number
Driller
Casing height
Wires properly protected (Y/N)
AT INSPECTION
MtJNICIPALI fY OF ?d,l,q IORAG}}
ENVIR()NM~NrAL SERVICk$ DIVISION
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout_
Petroleum tank __
g,p,m.
RECEIVED
WATER SAMPLE RESULTS:
Coliform Nitrate _
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ---.¢- Z ~ - <~,¢ _ Tank size /Z 5"O
Cleanouts (Y/N) ,'/ Foundation cteanout (Y/N) /V
High water alarm (Y/N) __ hJ//¢ _ Alarm tested (Y/N)
Date of pumping ~-- - /¢, ---~ Z.~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ¢ 3~'
To property line z/'~,
Surface water/drainage __~.~
Otherbacteria
Compartments 2_
_ Depression (Y/N)
On adjacent lots //¢ __Foundation
Absorption field Water main/service line
72-026(Rev. 3/91) Front MOA21 CONTINUED ON BACK PAGE
LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed ?/2 ~.//~'~ Soil rating
Length ~-~J Width .~ /
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellonlot ¢¢'¢' P~)r4m¢,~,'~
Surface water
System type
Gravel thickness 5, 5 ' Total depth
Cleanouts present (Y/N)
Date of adequacy test.
for ~/- _ bedrooms
If yes, give date
Property hne
To building foundation
On adjacent lots
Surface water
To existing or abandoned system on
.Cutbank ~4o~ ipA~A Watermain/serviceline
Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name /Y/J,(.:4q,4-t;'g, ~-'/'~~
Date ~/1~
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
WALTER J. HICKEL, GOVERNOR
DEPT, OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
(907) 349-7755
August 14, 1992
Mr. Dale Kruger
7041 Lowell Circle
Anchorage, AK 99502
SUBJECT: Tanaina Valley Subdivision (Country Lane Estates)
Class "A" Public Water System, PWSlD Z1,1706
Dear Mr. Kruger:
I have completed a review of this office's files concerning the status on the above-
referenced Class "A" Public Water System and found following:
Inorganic Chemical Contaminants:
Date of last samples on record:
Organic Chemical Contaminants:
Date of last samples on record:
Volatile Organic Chemicals (VOC's):
[:)ate of last sample on record:
Radioactive Contaminants:
Date of last sample on record:
Total Coliform Bacteria:
Date of last sample on record:
Final Operation Certificate:
Date Issued:
Outstanding Violations:
18 AAC 80.200
5/04/90
18 AAC 80.200
11/16/91
18 AAC 80.400
11/16/91
18 AAC 80.200
12/05/90
18 AAC 80.200
7/14/92
Country Lane Estates Well ¢/-2
10/29/87
No
Based on the above information, this Public Water System is in compliance with State
Drinking Water Regulations (18 AAC 80).
Dale Kruger 2 August 14, 1992
If you have any questions on the above comments, please do not hesitate to contact this
offioe at 349-7755.
Sincerely,
Michael Lu
Environmental Eng. Asst. II
ML/of
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) l. egal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner ~//~ ~ Telephone: (home) ~- ~/~7 BusinessZ~' ¢~/
Mailing Address ~¢¢/ ~¢~//
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here ~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family [] Number of bedrooms
3. WATER SUPPLY
Individual Well [] Community El'"" Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4, SEWAGE DIS/POSAL
On-site~ Public[] Community[] Holding Tank[]
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025(Re¥.7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the vaJidation 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 sdequate 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 sll Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm /~/,J/) ~.So~J ~-'/,J~,,Jc;~/L41d(~ Telephone ~ ~7~ ~-
Address
Date
Engineer's Seal
6, DHHS APPROVAL
Approved for ~ bedrooms by
Approved Disapproved Conditional
Terms of Conditional Approval ,//~/~.Z~
Date
[~F- 't'.4,'~M[']{ r~ rff
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description:
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth _ Cased to __
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
WaterSample Collected by
WaterSample Test Results
Date Completed
__ Depth of Grouting
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
Comments ~' I~' ,~_._
SEPTIC/HOLDING TANK D~,TA
Date Installed 7'2-~-~¢~ ~ize
Standpipes (Y/N) ~/ __Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING 'YANK:
To Water-Supply Well ~
To Property Line ,,,_z,¢¢"
To Water Main/Service Line -.~/
To Stream, Pond, Lake or Major Drainage Course
Comments
/Z~b No. of Compartments
)/ Foundation Cleanout (Y/N)
Date Last Pumped ~/Z ~,¢~ ~"
;for /~¢0
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
72-026 (Rev 7/88) Ftont Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
Length of Field
Depth of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Gravel Bed Thickness
7,~' Y Statndpipes Present (Y/N)
Date of Last Adequacy Test
/'2,4 5 5 E.D
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line ~ ? '
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots /o~
To Cutback (if present) /6
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ../¢'~.¢~.~'/,¢ ,~-/~P ,-t/
'""'I~L~ STATIO N
Date~ .
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA
inspection.
Signed
Company /¢r~ ~ ~'/'L,l O~
Date
MOA No.
uidelines in effect on the date of this
Engineer's Seal
ReceiptNo. _~c~-/~.~;) _~¢ 0 ~
Date of Payment
Amount: $
Receipt No.
Waiver Fee: $
Date of Payment
72-026 {Rev 7188) Back
Page 2 of 2
DEPT. OF ENVll~ONMENT/kL CONSEilVATION
STEVE COWPER, GOVERNOR
ANC[IORAGE T,r,,e,l,T~ nTC'T~Tmq~ OFFICE
3601 C ........... , SUITE 322
ANC~JORAG. ,, ALASKA 99503
563-6775
FOR: Wayne McFadden
Auguat 29, 1990
PWSlD: !t214706
,~UO..~, i. J99~
~ ':' ,: %(~ i~!¥(N~ I~I!S. BIO.
According to the records on file in this office, the cgun~.[y Lane
Estates 'Panaine Valley Water System is in compliance with the State
of Alaska Drinking Water Regulations.
st
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
r)IVlSION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
/~/~ q-A~A~ VAL&~U, '~,/ TIT~I ~q uti
Location (address or directions)
Ckl (~iO~_J,._L~i o,C:F
(b) Property owner ,17¢51~,,,/.5 !/,/ IA.f O0 o Telephone: (home)
Mailing Address '?&ZI D,~ hCTUJ O05
·
. Business
(c) Lending Institution
Telephone
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here D. if hold for pick up.)
List contact person and day phone number below:
2, TYPE OF RESIDENCE
SinCe-Family N mber of bedrooms_'
3. WATER SUPPLY
Well [] Community ~ Public []
Individual
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site~l~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72~25 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND iNFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functiona end adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage flies and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
NameofFirm ./~/J.0~-//_5o~J ~'~6),~'~"~"')~-v~/~ Telephone -.~.~7-~7
Address ~D. ~o~ Z~77~ ~CHC~ 6~ ~ ¢¢¢~¢
Engineer's Seal
6. DHHS APPROVAL
Approved for /7/ bedrooms by
Approved ~ Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) 8ack Page 2 of 2
MUNICIPALI'[ Y OF ANCt IORAGE
ENVI?,ONMENTAL SERVICES DIVISION
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: ~.-,¢'7-
', ",, '. 1 I. J!)88
RECEIV.ED
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
WaterSample Collected by
WaterSample Test Results
Comments ;~ 'Z~'I~
Date Completed
Depth of Grouting
I~)B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed _?/Z~//~-f2~ Size
Standpipes (Y/N) y Air-tight Caps (Y/N)
Depression over Tank (Y/N) _ /t,J
Pumping/Maintenance Contact on File (Y/N) ~ ~.
Holding Tank High-Water Alarm (Y/N) N lA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
IZ %~_ No. of Compartments
)/ Foundation Cleanout (Y/N) _.,V'
Date Last Pumped NF_.x.d
; for ^//4
Temporary Holding Tank Permit (Y/N)
To Building Foundation '~'
To Disposal Field _
To Water-Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments /,IL- u.) .'~0 ,~ %"F; ~ ,4 ~F_~?J.//¢ 7--~-'_
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area ,b"?,5"
Depression over Field (Y/N) /L/
Results of Last Adequacy Test
L~ / Type of System Design
Length of Field (~:¢ -'~/
Depth of Field r?, ~ /
Gravel Bed Thickness ,-~, ~"
Statndpipes Present (Y/N)
/
Date of Last Adequacy Test NE'Cd Coo
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well ~7-~~
To Building Foundation 7~/'
Lot /kit;nc ¢~ I ~-
To Water Main/Service Line ,.~ '? ~
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments Al~- l.d QOd%Tl~uc'r-~ o ~d -
To Property Line /¢'
To Existing or Abandoned System on
; On Adjoining Lots ~O' '/-
To Cutback (if present) ,L/o ~JE~ /~ rE'.5~-ca 7'
Dimensions
,S, ize in Gallons ~ Manhole/Access (Y/N)
Pump On" Level at -'~-._ "Pump Off" Level at
High Water Alarm Level at ~ Vent (Y/N)
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA gui,c~'~'"~Cc~t on the date of this
inspection. ,~.,~4¢. 01' ~
Company ~ ~ t~'b~ ~~ ~ ~~'~TH ~,. ~., .=_ ~}~ ~, -,~ ~'~"~ ~. ~
Date
~* ¢~ ~t&ch~el E Anderson , ~
Receipt No, d~-~¢7~/ ~L)7~ Receipt NO
Date of Payment ~0 '~//~ ~ Waiver Fee: $
Amount: $ / ~- ~ Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
DEI~]~. OF ENVIRONMENTAL CONSERVATION
ANC'HORAGE/JESTERN DISTRICT OFFICE
_,601 C STREET SUITE 1334
A~',ICHORAGE, ALASKA 99503
STEVE COWPER, GOVERNOI~
To Whom It May Concern:
accordinq to the records on File in this oFFice, the _CoOrD}4~ .....
· _~:y~4;~_~6~.~x~,~.~,~)Uaten System is in compliance with the
~tate 0¢ Alaska Orinkinq Water Requlations,
PSK:sa
Sincerely,
Environmental Field OFt~icer